Treating Wounded Soldiers: Beyond PTSD

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image by DoD / Fred W. Baker III
Navy Senior Chief Jim Pitts, a non-clinical case manager for wounded warriors, talks with Veterans Affairs social work supervisor Scott Skiles and Army Sgt. 1st Class Lee Smith, a wounded warrior military liaison.

View photos from the Polytrauma Rehabilitation Center at

Corporal Jason Poole was 17 when he joined the U.S. Marine Corps in 2000. On his third tour of duty in Iraq in 2004, Poole was in a group patrolling near the Syrian border when an improvised explosive device detonated, killing two Marines and an interpreter, and ripping off the top left part of Poole’s head.

He had surgery to repair and seal his skull and remained in a coma for almost two months. When he finally awoke to see the excited face of his twin sister, he was frightened and disoriented–although he laughs at the memory of reaching immediately for his head. “I thought I’d have some big Afro after two months,” Poole says, “but my head was shaved.”

Five years after that horrific blast, he sits in a visitors’ lounge at the Veterans Affairs Palo Alto Health Care System. He is blind in his left eye, deaf in his left ear. His right side is weak and his right arm heavily scarred. His hands and arms still contain scores of faint, freckle-sized black specks of shrapnel. But many subsequent surgeries have given Poole back a friendly and good-looking face whose scars do not overshadow his easy, bright smile. That in itself is something of a miracle. Not to mention the fact that he has relearned how to speak, how to eat, how to read, how to walk.

There is no official definition for polytrauma in most dictionaries, although it’s easy enough to figure out. Trauma is bodily shock or emotional injury. Poly is from the ancient Greek for many.

But at the VA Palo Alto’s Ward 7D, the Polytrauma Rehabilitation Center (PRC), the idea of “many” shocks and injuries barely does justice to reality. Palo Alto is one of four PRCs–along with those in Minneapolis, in Tampa, Florida, and in Richmond, Virginia–chartered in 2005 to address what the U.S. military acknowledges is a signature injury of its operations in Afghanistan and Iraq: traumatic brain injury (TBI) in combination with other combat wounds. Service members patrolling debris-strewn streets and crowded areas are vulnerable to booby-trapped roadside bombs that not only hurl shrapnel into and through body tissue at tremendous force and create burns, but also produce a shock wave that can severely damage the brain without any visible sign of injury.

Veterans with polytrauma often return with profound physical disfigurements, missing limbs, and serious organ damage. But their TBIs also produce myriad neurological symptoms, which can include amnesia, headaches, dizziness, vision problems, and the inability to concentrate, swallow, speak, or read. They also suffer from insomnia and nightmares. And they battle other common symptoms of posttraumatic stress disorder, such as a lack of impulse control, flashbacks, and irritability. Together, these issues affect their ability to think, to sleep, to see, to interact normally with others–even to recognize their spouses and children.

In March 2009 Pentagon officials reported that more than 350,000 service members returned from deployment in Iraq and Afghanistan might have suffered some form of brain injury. (This includes mild TBI, or concussion.) The Department of Veterans Affairs estimates that it has treated 8,000 brain injuries in this group. So far about 700 of the most gravely injured have been treated in the four PRCs, almost 200 of them in Palo Alto.

Patients spend an average of 42 days in Ward 7D. Those who are in a coma spend at least 90 days, most at least six months. During that time, an extraordinary number of specialists work with them. When program director Sandy Lai settles into a chair at her team’s biweekly meeting to discuss cases, she joins about 20 team members from physiatry, rehabilitation nursing, blind rehabilitation, neuropsychology, psychology, speech-language pathology, occupational therapy, physical therapy, social work, chaplaincy, nutrition, therapeutic recreation, and prosthetics. Virtually everyone has an opinion and a therapeutic or diagnostic angle on the patients under discussion; they comment on everything from the growing strength in one person’s injured leg to how to convince another person to take his medications. All are encouraged to contribute any insight or observation that may help. A speech pathology aide, for example, shares her discovery that one of the patients is particularly interested in basketball. These are the seemingly small but significant insights that can provide a window on motivating someone in a new way.

One aspect of these patients’ lives that demands a new approach is their youth. Before the wars in Afghanistan and Iraq, the VA facilities mostly were dealing with Vietnam veterans, who are much older, Lai explains. The Afghanistan and Iraq service members “do not want to play bingo as rehabilitation,” Lai says. “They have more energy, they are more technology ori-ented. They even have bigger appetites. We have redesigned the kitchens so they and their families can access food more easily; we have brought in Wii systems and personal computers for their recreational therapy.”

Because of their youth, these veterans also have families who are far more involved in their care than many older veterans’ families, and those families have expectations for recovery that the staff have to both support and manage. Lai, whose background is in family medicine, was instrumental in developing the four PRCs’ “family-centered care” philosophy, which from day one strikes a partnership with the injured service members’ families, including parents and, often, very young spouses who are overwhelmed by the tragedy.

“We always try to focus on the possibilities,” Lai says. “When we admit the patient, he or she may have a serious disfigurement. We try to focus on what we know is possible, that a prosthetic, for example, will eventually restore a normal-looking head to the patient, and that young people’s ability to heal is quite amazing.”

Jason Poole’ssunny demeanor masks the lingering consequences of his brain injury. He has no memory of the explosion that changed his life. He sometimes has trouble finding the right words, and it’s hard to concentrate when he reads. As we talk, a slight, pale young man who has been standing a bit uncomfortably near us suddenly pulls up a chair and announces, “I find when I join a group, the group stops functioning as it has been.”

Such jarring comments are not uncommon here. TBI robs many patients of the ability to empathize, read social situations, or interact as expected. Poole’s compassion and social skills are intact. He leans toward the anxious young man with genuine concern and reassures him that we’re simply in the middle of a conversation we need to finish. No hard feelings, nothing to worry about. In fact, he says, “I’ll catch up with you later, man.”

Excerpted from Stanford (Nov.-Dec. 2009), the eclectic bimonthly magazine of the Stanford Alumni

For more, view photos from thePolytrauma Rehabilitation Center.

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