The Polytrauma of War Severity of Injuries Requires New Forms of Rehabilitation

Never before have so many US soldiers survived such terrible injuries as during the current conflicts in Iraq and Afghanistan. Many have suffered multiple injuries, including brain damage. In special rehabilitation centers, caretakers are battling to restore the lives of severely injured GIs.

One sunny morning, not far from the Afghan city of Jalalabad, a United States military Humvee explodes. The driver and the gunner die instantly. The athletic man in the passenger seat is Sergeant Tim Wicks. He's 39 years old, from Bismarck, North Dakota. He has a German wife and two teenage sons, and he's been on active duty in Afghanistan for three months.

Wicks is catapulted back and forth inside the vehicle. Then he's hurled through the window. His spleen bursts, his left lung collapses and one of his kidneys is torn open. The fillings fall out of his teeth, his hipbones are shattered and his shins break.

He also suffers a concussion between the moment of the explosion and that of his body's impact. Billions of axons -- the fibrous projections that link nerve cells together -- are torn apart inside him. Then everything goes black. Wicks only wakes up from his coma 16 days later. He looks around, dumbfounded. He's lying in a hospital bed in the Walter Reed Army Medical Center in Washington, DC. He can't remember the explosion.

The novelty of the military operations in Afghanistan and Iraq is that more and more soldiers like Hicks are now surviving their injuries. The survival rate for US soldiers was never as high in any previous military operation. The reasons include the new state-of-the-art, bullet-proof vests that soldiers are equipped with and the fact that mobile army field hospitals are equipped with the best technology available. As of early October 2006, the number of American soldiers killed in Iraq and Afghanistan was 3,094; the number of injured soldiers was 21,649. That's seven injured soldiers for every dead one. During the Vietnam War, the ratio was only two or three to one.

But there is a high price to pay for this achievement. A disturbingly high number of young US citizens are returning from Afghanistan and Iraq with serious cases of brain damage. Most of them were injured by mortar, grenades or other explosives. Bullet-proof vests may protect the heart, but not even Kevlar helmets can offer complete protection for the head. Shrapnel can make its way into the brain via the face, the forehead or the nape of the neck. The blast wave moves through the skull like a thunderstorm, and the brain is rocked back and forth inside the cranium. Arteries are torn open, and brain tissue swells dangerously.

That's what happened to Wicks. When he was still in Afghanistan, US Army surgeons drilled a hole into his skull in order to relieve the pressure that had built up inside his cranium. It was only then that he was flown to Washington, DC, via Kuwait and Germany.

When Wicks woke up in Washington, the right side of his body was paralyzed. But he was able to recognize his wife -- she had waited by his bed for days. He asked her about the "two boys" quietly, but couldn't believe that the 17 and 18-year-olds in the photograph by his bedside were his sons. He was also convinced that he still lived in Germany -- where he had in fact once been stationed. According to the calendar, it was June 21, 2006, but Wicks thought he had woken up in the 1980s.

The $35 billion hidden cost of war

More than 3,000 American soldiers have suffered brain damage in Afghanistan and Iraq. In half of these cases, the trauma will lastingly affect their capacity to think, their memory, their mood, their behavior and their ability to work. Many of the victims are hardly adults, barely even 20. And many of them will require special treatment for the next five, six or seven decades. A joint study conducted by Harvard and Columbia unversities estimated that the cost of caring for them will be at least $35 billion.

Many of the soldiers affected haven't just suffered brain damage. They've also been mutilated so badly or have have suffered so many severe burns that the term "polytrauma" has become a common one for military doctors.

The number of soldiers with these types of mulitple injuries is so high that US government had to create four so-called "polytrauma rehabilitation centers" last year -- in Palo Alto, California; Tampa, Florida; Richmond, Virgina; and Minneapolis, Minnesota. There, the "latest generation of America's heroes" -- as the injured soldiers are called in a statement issued to their relatives -- is shielded from the public.

Wicks was transfered to the polytrauma rehabilitation center in Minneapolis, Minnesota at the end of July. Of the four centers, it's the one closest to his home in North Dakota. He shows a picture of himself taken by a fellow soldier a few days before the explosion that changed his life forever. The man in the picture wears an olive bandana, has a cigar stub in the corner of his mouth, and is holding an M4 semi-automatic firearm. He looks self-confident. His wife loves the picture -- she says it captures perfectly what he used to be like.

Wicks grew up in the sparsely populated state of North Dakota and signed up for military service as a high school student. He needed permission from his parents, as he was only 17 at the time. Not much later, he was stationed in Erlangen, Germany, where he met a young German woman at a nightclub. Tim and Angie married four days after she turned 18, had two sons and in 1993 moved back to North Dakota. There, Wicks became a member of the National Guard, although he was also a reservist for the US Army. Early in 2006, he was sent to Afghanistan.

Now Wicks is confined to a wheelchair -- he has to avoid straining his left hip for the time being. His bleeding spleen was removed. His slashed kidney is back in working order, thanks to dialysis treatment. The doctors removed a loose bone splinter from his legs. They drilled metal screws into his hip, drove nails into his knee and fixed his shinbones in place with titanium rods.

The T-shirt Wicks is wearing hangs loosely around his shoulders. He's lost 30 kilograms (66 pounds). His voice sounds hoarse -- he kept removing the tube inserted into his neck to help him breathe, and when the doctors urged him not to, he forgot what they had told him within a few minutes. He had temporarily lost his short-term memory.

A new kind of patient

Every patient who comes through the doors of the polytrauma rehabilitation center in Minneapolis suffers from a specific combination of different injuries, explains Larisa Kusar, one of the doctors working there. "For about three years now, we've been seeing a new kind of patient," she says. "Many of them would have died in Vietnam." It's not unusual for 12 specialists to deal with a single case.

Kusar hesitantly presents a CT scan showing the skull of a soldier injured in Iraq. A piece of shrapnel from an exploding grenade shot through his right eye and buried itself deep inside his brain. The piece of shrapnel has a diameter of five millimeters (0.2 inches). In the image, it gleams like a bright particle inside the dark tissue surrounding it. But there's something else that isn't normal: A full third of the skullcap is missing.

A soldiers' sacrifices

The doctors sawed it off on purpose. Thanks to this so-called "decompressive craniectomy," the injured brain tissue was able to swell, Kusar explains. Later on the hole in the cranium will be sealed with a steel plate.

The doctor proceeds to the next patient, speaking quietly. He's about 20 years old and tried to defuse a bomb built by an insurgent in Iraq. The attempt went badly wrong. The young soldier lost both arms and his sight. The blast wave that moved through his skull reduced his mental capacity to that of a small child.

"We know what sacrifices these soldiers have made," Kusnar says. "Now we're concentrating on improving their lives -- on making sure they can make the greatest possible use of the abilities they have retained."

The doctors in Minneapolis have at least been able to treat the patient's brain to the point where he has been able to return home. He lives in a suburb of Minneapolis with his wife and two small children and is currently undergoing rehabilitation training for the blind.

Compared to the young soldier, Tim Wicks is making great progress. Orthopaedists are currently restoring mobility to his legs by means of titanium and bone cement. Making his mind agile again is a task reserved for occupational and speech therapists. Day after day, they present him with increasingly difficult problems to solve.

At first, the therapists asked him to tell them what day and what year it was and where he was every couple of minutes. For a time, Wicks had to think hard before answering, but at one point he replied: "Hey, didn't I just tell that to your colleague?" His short term memory was slowly returning.

In the polytrauma unit's handicraft room Wicks has already disassembled and reassembled a gasoline-powered lawn mower three times. He puts the components that are left over in a plastic bag -- each time there are less of them. His memories of what happened to him since the 1980s have also been returning -- in chronological order. Wicks now seems perfectly normal in conversation, apart from the odd absent-mindedness that sometimes overcomes him. "Learning new things takes a little longer than it used to," he explains.

The story of Wicks's recovery is reassuring to the 38 employees at the polytrauma unit. Their efforts have clearly produced remarkable results: The severed links between nerve cells have reconstituted themselves. The paralysis of the right side of his body has all but disappeared.

Not even the doctors know exactly what goes on with nerve cells during such a recovery. But speech therapist Jack Avery suspects that "patients use their brains in a different way than before."

Two weeks ago -- just over four months after the explosion in Afghanistan -- Wicks was using his restored brainpower to start making grand life plans. He wants to return to his sons and buy or build a bigger house. He wants to pass a fitness test for injured soldiers so that he can re-join the National Guard.

Wicks has to perform another five years of service -- only then will he be entitled to a full pension.

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