Broken Brains

Traumatic brain injury is the signature injury of the wars in Iraq and Afghanistan, and many soldiers suffer in silence. New treatment can heal the wound.

Fort Bragg, NC — Four and a half months into his stint in Afghanistan as a Special Forces medic, Karl Holt had a hand in saving life and comforting the dying.

He treated a local man, carried in lying on a sheet of plywood atop a wheelbarrow, so mangled by an explosion that the then-32-year-old medic from Houston couldn’t tell bits of bone apart from gobs of flesh. Holt wrapped the man in blankets for warmth as he died.

When a homemade bomb ripped through a convoy, Holt helped get an IV into a wounded soldier and had him evacuated so fast that he survived despite suffering burns over 92 percent of his body.

Not every mission was so gruesome: One night raid ended with a dog bite as the only injury.

In up to five missions a week, Holt learned one truth about the Taliban: What they want most is to brag about the Americans they have killed.

That fact kept Holt alert while securing the perimeter during another night raid on Oct. 26, 2009. Holt cordoned off his area for hours while other members of his team assaulted a compound in northern Afghanistan that housed traffickers in drugs and weapons. At one point, an RPG round flew by Holt so close that the blast of air knocked him to the ground.

At about 3:30 in the morning, the sounds from a pair of Chinook helicopters pierced the air. It was time for the Special Forces unit to go.

Thick smoke and flames from the firefight covered the scene. Even the soldiers wearing night vision goggles couldn’t see the helicopters.

Holt guided himself by the whoosh of the rotor blades. He knew he was close when the wind whipped by the Chinooks slapped sand into his face.

Enemy fire poured into the landing zone as Holt boarded one of the helicopters. The pilot took off.

Holt knew mountains loomed in the darkness and confusion. Seconds before slamming into a high cliff the pilot pulled up on the controls. The Chinook, angled nearly 90 degrees, lost power and began to fall.

Crashing into a two-story compound, the helicopter broke into two pieces. Holt blacked out.

When he awoke Holt found himself buried under a mountain of equipment. His first thought: I am alive. His second thought: I can’t breathe.

He forced out a lungful of air, spitting out most of his upper front teeth along with his desperate breath.

Lost teeth were the least of his worries. With the crash’s flames bearing down, Holt threw off the equipment that had him pinned. He soon realized that part of what he had to remove included body parts of the dead.

He didn’t have time to consider the gruesome scene. The heat inside the helicopter cooked off round after round of ammunition, which began to pop and crack.

Holt crumpled to the ground when he tried to stand. It was crawl or die.

He dragged himself toward the screams of those outside who were begging for the rest to escape.

Holt was the next to last soldier to make it out alive. Ten Americans died. With 16 wounded soldiers, Holt was the only medic on the ground. But he had his own injuries: a shattered top jaw, a broken back, two dislocated shoulders, a fractured left leg, and ruptured left ankle tendons.

Holt’s war in Afghanistan had ended. But a new battle had just begun. It was one that would rage long after his ruptures, fractures, broken bones, and dislocations had healed.

When he lost consciousness on the helicopter, Holt suffered a Traumatic Brain Injury (TBI) that, remaining untreated for nearly two years, continued to fester. It transformed Holt from a soldier who kicked in doors in Afghanistan to a man who had to put sticky notes on the door of his North Carolina home reminding him to lock it before leaving. 

Military doctors are calling TBI the signature injury of the wars in Iraq and Afghanistan. Between 2000 and Aug. 20, 2012, there have been 253,330 reported cases of TBI among all members of the Armed Forces, according to the military’s Defense and Veterans Brain Injury Center. Of that number 147,536 have occurred in the Army.

Concussions are a form of TBI. But these are concussions delivered by hits more jarring than those that come from a charging 230-pound NFL linebacker.

As with Holt, accidents and crashes occurring in the pressure cooker of the battlefield (or in training on a stateside military base) can cause a TBI injury. Improvised explosive devices, or IEDs, the weapon of choice for insurgents fighting U.S. forces, have caused many of the military’s combat TBI cases.

More soldiers are coming home with TBI symptoms simply because more soldiers are surviving other wounds that would have killed them in previous wars. Soldiers whose heads got rocked by an explosion along the beaches of Normandy or the jungles of Saipan during World War II or inside the tunnels of the Viet Cong during the Vietnam War probably died from visible physical wounds long before doctors had a chance to discover the aftereffects of the blasts on the soldiers’ brains.

But improved protective gear, advancements in medical technology, and a triage system that yanks severely wounded soldiers out of the battlefields and into military hospitals in Germany and the United States have given military doctors thousands of new patients who are experiencing the consequences of rattled brains.

These invisible wounds often go undetected, and they are hard to explain to patients and their families.

If a brain is like a city where information travels along roads from building to building, then TBI unleashes an earthquake on that city. Usually it’s the type of earthquake that doesn’t knock down the buildings. But it damages the roads enough to disrupt the way the brain communicates. In extreme TBI cases, even the buildings are knocked down, crippling the patient’s mental capacity.

TBI cases are divided into subcategories. Doctors have classified about 77 percent of the military’s TBI cases as mild, including Holt’s injury. Nearly 17 percent of cases have been labeled moderate, while just 1 percent of cases have been diagnosed as severe. The classifications depend on the length of unconsciousness, disorientation, and memory loss.

In a mild case, a loss of consciousness lasts 30 minutes or less while confusion may persist for less than a day. A loss of consciousness for more than 30 minutes but less than a day with disorientation that persists more than 24 hours characterizes moderate TBI. A severe case occurs when the victim losses consciousness for more than 24 hours and endures acute memory loss for more than a week. Penetrating TBI is an open head injury occurring when membranes covering the brain are penetrated by objects like projectiles, knives, or bone fragments.

Doctors stress that the labels “mild” to “severe” have more to do with the duration of the injury and not the aftereffects suffered by the patient. Those include a wide range of symptoms that can vary from person to person in quantity, duration, and intensity. Bouts of vomiting, sleeplessness, persistent headaches, sensitivity to light, memory loss, mood disorders, inability to focus, slow reaction time, dizziness, depression, blurred vision, and loss of balance are some of the problems that arise when parts of the brain lose the ability to function. These problems can last weeks, months, or years, even for patients with mild TBI.

Such was the case for Holt.

After his visible wounds healed, Holt, now 35, told everyone that he was fine. “I’d call it the recovery of the century,” he said. But his hidden wounds continued to wreak havoc on his daily life.

While driving he’d be so unsure whether he had locked his doors that he’d return to his Raleigh, N.C., home even if he’d already gone 45 minutes down the road. He couldn’t find his car in a parking lot. Reading gave him headaches. He kept losing his place so much that after finishing a page he wouldn’t be able to recite what he’d just read. He’d forget names.

It was a frustrating contrast for Holt, who had endured 15-hour days of intense study and testing for months while in the Army’s medic school.

Still, he didn’t want to go public with his problems. He thought that admitting the weakness would be another sign of weakness. He was fearful of the stigma he’d face as a Special Forces soldier who suddenly couldn’t remember to put cold food back in the refrigerator. Maybe he wouldn’t be able to rejoin his unit.

For two years he endured a life with a brain operating in slow motion like a computer frozen by too many open applications.

He began to adapt. He left notes to himself all over his house:

Make sure the alarm is on.

Turn off the air conditioner.

Put the trash out.

Make sure nothing is in the sink.

Lock the back door.

He woke up most nights so concerned about what he had to do the next day that he couldn’t go back to sleep. So he’d get out of bed and make more lists. “I was certain that if I had a thought and didn’t write it down then I’d lose it,” he said. “I just had to get really detailed. I was so amped up about forgetting something that it was all-consuming.”

Holt was not the only soldier trying to navigate a confusing new world and determined to avoid seeking help. Every morning when Donald Jarvis applied his deodorant three or four times or brushed his teeth two or three times, his roommate would laugh. “You just did that like 10 minutes ago,” his roommate would say to a skeptical Jarvis.

There was a reason why Jarvis, 26, even had a roommate in his apartment at Fort Belvoir, Va. One week after he tried living alone, he began cooking a package of Ramen noodles and then went to bed. He woke up when the fire alarm went off. To his surprise smoke had filled the apartment. He’d forgotten about the noodles.

This is the new life Jarvis leads, “since I’ve been blown up,” as he often describes it. Last February, during a patrol in Afghanistan, a 250-pound homemade bomb exploded over the mine-protected clearance vehicle, called a Buffalo, driven by Jarvis, an Army specialist. The blast knocked the six-wheel, 13-foot-tall, 76,000-pound vehicle onto its side.

Returning home, Jarvis battled daily headaches that escalated in intensity as the day progressed. Bright lights, sudden noises, and loud crowds left him overwhelmed. The mix of forgetfulness, headaches, and confusion left Jarvis frustrated and easily angered.

He found it harder to endure his injuries because, no matter how hard he tried to explain his symptoms and feelings to others, he saw glimpses of doubt in their eyes. “If I were to lose a limb, I’d only have one arm so you’d kind of notice,” Jarvis said.  “Although we may appear to be good, the damage is on the inside. You may not see it, but we feel it. We notice that our life is different. I have kind of just accepted it for what it is worth. What else can you do?”

Heechin Chae, the chief of the Department of Traumatic Brain Injury at Fort Belvoir Community Hospital, says this frustration is common among TBI sufferers. The added mental stress often slows down recovery. That healing process, Chae adds, is further impeded by one of the biggest obstacles to treating TBI: the inability of its sufferers to admit they need help. Such invisible scars are easier to hide than physical disabilities, especially on the battlefield.

John Butler, a commercial fisherman from New Bedford, Mass., who joined the Army soon after the 9/11 terrorist attacks, survived a 120-pound bomb blasting just several meters behind Butler’s armored vehicle. Soon after the August 2011 incident Butler, 31, could neither drive nor walk in a straight line. Despite his symptoms, Butler fought to remain deployed in Afghanistan. He often hid at the sprawling military base from any officer who had the power to send him home.

“I just kept getting on patrols and doing the best I could to stay with my platoon,” Butler said. “I feel very lucky that I was able to stay in the fight. That was the key. I mean, you are a team.”

Back home one year later, Butler has to hold onto walls to keep his balance when he walks. Things around him seem to be in motion. When other people are present Butler will stop and look. If no one is staring at him then he knows he must be walking straight.

Butleronce tried driving at night. He kept thinking that the lights of the cars coming the other way were headed right toward him. He worried that he wasn’t driving straight enough to stay on his side. At one point he stopped eight times to refocus before reaching his destination. It left him shaking for more than an hour.

“I didn’t want to say anything because I don’t want people to think I’m some whack job who’s going to freak out at any second,” Butler said. “I don’t want to be looked at in that way. Part of me feels like some of it is never going to come back. Some people have a bad knee, I’ve got a bad brain.”

The military medical community has spent the last several years convincing TBI sufferers like Butler that their bad brains can heal with the proper therapy.

Granted, there are extreme cases of TBI that include prolonged, sometimes indefinite, loss of consciousness. In these cases, the brain is not able to orchestrate the basic mental tasks of daily living. Caregivers are required to assist with activities eating and bathing. Some of these patients may be able to open their eyes and even recognize the presence of another person in the room, but they have lost the ability to communicate.

Other patients face immense pressure due to swelling brains. They have to have portions of their skull cap removed and wear helmets until the brain’s proper size is restored.

But the vast majority of TBI cases are temporary due to the brain’s ability to repair, regenerate, and reconnect, a concept called neuroplasticity. “If you have a weak muscle you are going to lift weights to get it strong,” said Steven Lewis, a neurologist with the Womack Army Medical Center at Fort Bragg, N.C. “Just like an unworked muscle will atrophy, many untreated cases of TBI won’t improve the longer they are ignored.”

Using an earthquake analogy, the brain’s TBI-damaged roads can be repaired. And in those cases where the brain’s toppled buildings and destroyed roads are wrecked beyond repair, the healthy parts of the brain can compensate by learning to handle new functions.

“It is like the department of defense takes over for the department of finance because the department finance is not there anymore,” says Dr. Chae, who also is the site director of the Defense and Veterans Brain Injury Center at Fort Belvoir. “But it takes time and training for that to happen.”

The science on TBI is still developing. In 2007, Congress provided the military with $300 million for TBI research. That initial TBI appropriation now has grown to more than $600 million.

The Pentagon opened a $70 million TBI center for treatment and research in 2010 at the Walter Reed National Military Medical Center in Maryland. In an effort to provide soldiers with care closer to their home bases, the military plans to open at least nine TBI satellite rehabilitation centers at major military installations across the country, such as Virginia’s Fort Belvoir and North Carolina’s Fort Bragg.

With the brain being one of medical science’s last fully uncharted territories, there are no surgeries that can repair or pills that can restore a TBI patient’s altered cognitive functioning. Instead the treatment program is grounded on two pillars: rest and a battery of mental exercises that can help a brain learn new pathways for internal communication.

In Fort Belvoir, where 95 percent of the TBI cases are mild, one of Chae’s tasks is convincing soldiers used to an active lifestyle that rest is needed to nurture a healing process that can take days, weeks, or months.

“Playing video games is not resting,” said Chae, repeating a refrain he often has to tell the current generation of soldiers. “People don’t know how to protect their brain for neuroplasticity to be completed. We become coaches until that process happens.”

Retraining the patient and the patient’s brain requires an interdisciplinary treatment team of doctors, therapists, counselors, and social workers. They unleash a battery of drills designed for the mind instead of the body. The activities vary from patient to patient since each individual brain copes with the trauma in different ways.

Jarvis’ symptoms include an inability to sleep more than three hours a night and a tendency to get confused around large groups of people. So his rehabilitation involves an occupational therapist who teaches techniques for handling crowds and a sleep coach who demonstrates relaxation exercises.

Kurt Garrett, 44, suffered multiple TBI incidences as a deployed Marine. The chief warrant officer returned from Iraq so disoriented (he’d check the kitchen trash for scraps to know whether he had eaten) and with a personality change so pronounced that his wife told him he was not the man she married. At Fort Bragg, he sees a neuro-optometrist who helps correct his eye movement and eye focusing abnormalities. The therapy involves machines similar to the ones found in a typical eye doctor’s office. But it also employs objects found at any craft store such as a string with multicolored beads that is tied to a door handle.

Patients like Garrett sit on a chair with the untied end of the string stretched to their nose. They train their eyes to remain focused on a bead of specific color as a therapist moves the beads up and down the string. Garrett, who was knocked out for 15 minutes when a steel beam fell on him while seated in a gun turret, also wears 3D glasses to follow two identical clown drawings as they are moved closer together and farther apart. Repetitive speed drills such as timed word searches help retrain his eyes to focus and then communicate with his brain.

“By the time I am done with an hour of that, I feel like I have done six hours of physical therapy,” said Garrett, who performed 237 patrols while assigned as a mentor to an Iraqi infantry company. “I am worn out.”

At Fort Bragg, where the return to duty rate for TBI patients is 90 percent, therapists use a 5-foot-tall touchpad grid, called a Touch Wall, for balance training — one of the things often lost with TBI. The wall’s 64 squares each contain an LED light that can flash different colors at different speeds. Told to hit only grids that display certain colors, soldiers track the color patterns with their eyes while balancing themselves on a foam pad. The timed sessions can get competitive. Nearby, a “brain bike” integrates physical activity with cognitive tests by using a video touch screen above the handlebars that provides brainteasers for the peddling soldier.

After suffering through a divorce and having to drop out of classes for an advanced degree, Special Forces Sgt. Holt admitted he needed help. He began going through neuro psychology and visual rehabilitation therapy starting in January 2012 — more than two years after the deadly helicopter crash. Early in his treatments the exercises would cause headaches so severe he would have to sit in the doctor’s office for 30 minutes before leaving.

One of his therapists, Evelyn Galvis, a speech and language pathologist at Fort Bragg’s Womack Army Medical Center, uses tools as simple as a deck of playing cards, a magazine, and worksheets of memory games to make patients like Holt miserable.

During a recent session, Galvis dealt eight playing cards face down. Flipping over one card at a time, she suggested a memory device for remembering each card.

“It’s 10 of diamonds,” she said. “Remember the time you gave your wife 10 diamonds.”

“Here’s the two of hearts,” she said while flipping over the second card. “Remember the saying, ‘two hearts are better than one.’”

Returning each card to a face-down position, Galvis asked the patient to look at two seemingly identical pictures that have a dozen slight differences. It’s a game found in the pages of most elementary school brain-teaser magazines.

Once the patient listed the differences, Galvis set those aside and verbally gave the patient a series of four numbers to be repeated in reverse order.

Several sequences of numbers gave way to new sequences of objects that had to be renamed in reverse order:

Pansy. Tulip. Rose.

Arm. Leg. Neck. Head.

After several lists and without a break, Galvis pointed to one of the face-down playing cards and asked, “Which one is that?”

She pointed to another. Then another.

Still moving fast, she grabbed the two pictures and asked the patient to rattle off the 12 differences, this time without looking at the pictures.

As patients get more advanced, Galvis will introduce distractions. She turns on a radio in the corner, playing the music at varying volumes. Sometimes she bounces a rubber ball off the opposite wall as the patient tries to concentrate.

One of the challenges surrounding TBI is that it’s hard to detect on the battlefield. Still, the military has begun attempts to identify and treat TBI in combat zones. Medics are trained to assess the orientation, memory, and concentration of soldiers who are near a blast, suffer a blow to the head, or get in a vehicle accident. These screenings, made mandatory by a 2010 Pentagon directive, occur even if the soldier does not appear to be hurt.

The military also has opened a dozen concussion restoration care centers throughout Afghanistan. Here soldiers who don’t pass initial tests receive orders for rest and additional neurological evaluations. Army medics in Afghanistan are field-testing a blood test, similar to those used to measure a diabetic’s blood sugar, to determine if a soldier has damaged brain cells. Research has revealed that certain proteins in the blood may be present only when brain cells have been harmed.

The military has ordered nearly 50,000 sensor helmets with the ability to measure the severity of blows to the head and to detect the potential for concussions. The National Football League is partnering with the military to place similar sensors in the helmets of professional football players.

The technology is helping soldiers become more aware of injuries few knew existed before the wars in Iraq and Afghanistan.

Back at treatment centers, camaraderie among the TBI patients helps with recovery. At Fort Belvoir some of the patients joke that they ought to become professional boxers since their heads have already taken a few lumps. But the military hopes to create greater TBI awareness among the general public where, soldiers say, a stigma still exists.

“Outside of here they know T,B, I are three letters that stand for something, and when you tell them it’s Traumatic Brain Injury, the word traumatic freaks them out,” Jarvis said.

For months Holt underwent mental drills on a weekly basis at Fort Bragg. He then went home to play additional memory, math, and hand-eye coordination games and puzzles.

Today there are a lot fewer notes stuck around Holt’s house. It has been months since he had to turn around and drive home to check whether his door is locked or his garage door closed.

He resumed taking college classes at Campbell University: 16 credit hours one semester that included chemistry and microbiology. He earned all A’s in a recent semester. He wants to go to medical school.

In the meantime, he works as an instructor at Fort Bragg helping new Special Forces soldiers become medics. To the trainees, he doesn’t talk much about the crash or his physical or mental injuries. But he does have some advice for soldiers who may be silently suffering through TBI: “It is not a derogatory term. It is not career-ending. Hiding it from everyone else is derelict. You could get other people killed. If you don’t ask for help, it makes you less of a man.”