The Heroes, The Healing

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."