A Different Battle

Corporal Michael J. Oreskovic’s Army unit was traveling along a dusty road near the town of Mosul, Iraq on October 11, 2004, when word came down the line to be on the lookout for a brown Ford Focus, which, sources told US intelligence operatives, contained a car bomb built by Iraqi insurgents. The information was half right. There wasn’t any Ford Focus, but there was a bomb. It was concealed in a pickup truck designed to look like just another farmer taking produce to market. Oreskovic, in the turret of an armored Stryker vehicle, fired at the truck as it barreled forward, but he and the rest of the men in his unit who pumped round after round into the careening vehicle couldn’t stop it. “All of a sudden, boom,” Oreskovic recalled. “We got blown up.” Two soldiers were killed in the blast, and eight were wounded.

Louis M. French, neuropsychologist at Walter Reed Army Medical Center, evaluates soldiers for traumatic brain injuries suffered as a result of explosions during combat in Iraq.

Oreskovic, a 23-year-old from Eugene, Oregon whose short, reddish hair and freckled complexion have saddled him with a classic all-American bearing, glanced away from the visitors in his hospital room and looked down at his left shoulder. His countenance – which was stoic, even clinically detached, as he recited a story he’s told dozens of times in the week since the attack – changed when he looked back up, becoming a mask of pain and anger as he recalled the explosion. “It took my arm off,” he said firmly, but his face suggests he’s still not used to the idea.

After 11 months of fighting in Iraq, Oreskovic faces a different kind of battle back in the United States. He’ll spend perhaps a year recuperating at the Walter Reed Army Medical Center in Washington, DC. His physical injuries related to the amputation of his arm are being dealt with; he’s had eight surgeries and may have more. Eventually he’ll be fitted for a prosthesis that will take the place of most of his left arm, starting just above the elbow.

Right now, however, Oreskovic is being examined for wounds far more subtle, but perhaps just as debilitating, as the loss of an arm. Louis M. French, a clinical neuropsychologist and chief of Clinical Services for the Defense and Veterans Brain Injury Center at Walter Reed, quietly asked Oreskovic a series of seemingly innocuous questions, looking for evidence of traumatic brain injury related to the explosion that tore his arm from his body.

Earlier, in his office, French explained the nature of the problem. Unlike previous conflicts, where doctors treating the wounded typically expected to see injuries caused by bullets or shell fragments, the most common type of wounds in Operation Iraqi Freedom have been blast injuries, such as those caused by a grenade, land mine, mortar, and what’s become known as an improvised explosive device, a bomb cobbled together from the bits of flotsam scattered throughout the wartorn nation of Iraq. About 64 percent of those wounded in Iraq received their injuries because of some sort of blast, according to the office of the Surgeon General of the Army.

While medical personnel immediately treat the sort of brain injuries caused by a penetrating wound, such as those left by shrapnel, French and his colleagues at the other seven Defense and Veterans Brain Injury Centers around the country believe that such “open” brain injuries are only part of the problem.

Better protective gear and improved medical treatment in the field are letting soldiers survive the blast explosions, instead of simply perishing as they have in earlier conflicts. But those blasts are dramatically increasing the number of those suffering from closed brain injuries, caused by the shock of the blast itself, by a soldier being picked up and thrown some distance away, or by being struck in the head. Soldiers suffering from traumatic brain injuries experience headaches, sleep difficulties, decreased memory and attention span, slower thinking, irritability, and depression. While all those symptoms don’t appear in everyone with a traumatic brain injury, French said they are often early clues that such injuries exist. For example, many patients with a closed injury due to a blast often have little recollection of exactly how the injury occurred.

“People who get shot in the head frequently remember the whole event with complete clarity; that’s a very common sort of story,” French said. “With a closed injury you frequently get this loss of consciousness or disruption of encoding for the period immediately after.” Such clues are a key aid in initial screening, and early recognition and treatment can help speed recovery.

So far, the program has examined about 450 patients for evidence of traumatic brain injury, and found it in 355 of them. About 84 percent of those were closed injuries. APS Fellow and Charter Member Lynn C. Robertson, University of California, Berkeley and VA Medical Center, Martinez, said the issues raised by French’s research deserve further study.

“There are all sorts of interesting things that should be examined,” Robertson said. “For example, when you have a penetrating missile, you’re also more likely to have a more circumscribed lesion.”

Robertson said that because these types of injuries are so new, it’s likely that they will take on many forms over time, which will require yet more examination.

“You get different types of damage to the brain if you’re hit in the forehead than if you’re hit in the side of the head, because the brain is like jelly,” Robertson said. “The inside of the skull has all these sharp edges that will tear at the brain as it moves around inside the skull. So you’ll get different types of injuries when the force moves the head from front to back as opposed to side to side.”

French quizzed Oreskovic to see if the wounded man needs a more complete evaluation. But Oreskovic isn’t really exhibiting the warning signs of traumatic brain injury, though he hasn’t completely left the horrors of combat behind him.

“I’m not really sleeping as heavily as I used to, but I was like that in Iraq, too,” Oreskovic said, as though he had been fighting a war years ago, not eight days ago. His cognitive functions are also fine, he said, as are his powers of recollection. “I remember everything,” he said, glancing at his left shoulder. “Probably more than I should.”

French is obviously relieved. He assured Oreskovic that while the soldier will have to put up with a few more tests, he doesn’t appear to have suffered any significant traumatic brain injury. Oreskovic, whose demeanor varied from numb to angry during the interview, brightened at this news and actually flashed a smile. French made his goodbyes, and once in the hallway, gave everyone around him a moment to compose themselves before moving on to see the next patient.

This screening system is fairly new, French said, and the program is still collecting data to help define research questions that must be answered. “One of the things that really got us working on this was we work very collaboratively with the other services at the hospital, and we started getting calls from the physical medicine people,” French said. “They said they had patients who’d lost a limb, but they were concerned because something else didn’t seem quite right. These patients were forgetting appointments, there were issues about patients remembering things about wound care, things like that. There were concerns that things were going on beyond the typical post-trauma that you might expect when somebody loses a limb.”

About a year and a half ago, French said, he got the blessing of hospital commanders to screen patients based on the mechanism that caused them to be hospitalized. “We look at everybody who’s been injured because of a blast, or a fall, or a motor vehicle accident, anything that could have potentially caused a brain injury. We go in and actually do the screening, and what we’re looking for is anything that suggests they’ve had a brain injury. Obviously, with some people it’s clearly documented that they’ve had a brain injury, but we’re talking about people at the milder end of the spectrum, with subtle injuries. We’re certainly treating people with more severe injuries, but these people at the other end of the spectrum very likely had other injuries that have been the focus of attention up till now – this person has lost a leg, lets take care of that.”

Screeners look for clues that something may have rattled the brain within the skull like a peanut in its shell. Questions include: Did you lose consciousness? Did you have any alteration of consciousness? Do you remember what happened?

“We’re basically trying to determine if they are symptomatic in any way, displaying typical post-concussive symptoms,” French explained. “In post-concussive symptoms, we’re really looking in three domains: One would be physical symptoms, such as sleep disturbances, headaches, and sensitivity to light or noise. The second area is emotional things: Mood changes, irritability, and personality changes such as apathy or impulsivity. The third area is cognitive: Attention, memory, language, problem solving. We assess to see if there are any changes in any of those domains.”

But drawing the line between a critical brain injury and the normal emotional swing that results from returning from war is not so easy. “One of the things that complicates this is that there’s an overlap between the kind of injuries we’re looking for and other things. Obviously a young, healthy guy who gets injured in a war and finds himself in a hospital is not going to be happy. You’d expect that person to be a little sad about things; that’s common sense. One of our challenges is differentiating a normal stress reaction to symptoms that may be related to a brain injury.”

That initial screening is critical to rapid recovery. “If they screen positive, we start them on a more comprehensive evaluation,” French said. “We’ll do audiometric examinations, because if they were close to something that blew up it’s possible they’ve had damage to their hearing. We’re doing imaging as necessary, blood work, physical exams, cognitive testing, neuropsychololgical testing, which can be brief or more extensive depending on what the issues are.”

Despite all the screening and brain imaging technology, precise identification remains problematic. “The issue of mild traumatic brain injury and concussion is a difficult one. Many people with these injuries don’t show evidence of trauma using standard imaging techniques, such as a CT [computerized tomography] scan. Sometimes we can’t put a person in an MR [magnetic resonance] scanner because they’ve got metal shrapnel in their bodies. Sometimes if we do use the right techniques, we can pick up evidence of physical changes. But for some of these people, it’s possible that there have been physical changes that just can’t be visualized by conventional imaging.”

Yet the damage is clearly there, French said, and identifying it can be a matter of life and death, not so much from the injury sustained as the possibility of a more serious injury after recovery. “Many of these people are going to show complete recovery over the course of time, but in the meantime they’re likely to suffer symptoms. And in an active military population, even things like slightly slowed reaction times or problem solving times can be a big issue. If your job is to react quickly, to see something and decide whether it’s friend or foe and then press a button to send off a missile or whatever, this is a critical issue.”

Treatment varies wildly, he said. Some patients simply recover with time, others benefit from education on how to safely recover – avoiding risky physical contact, drinking too much alcohol, or placing themselves in high-stress environments. Those with stronger, persistent symptoms must be treated with a more individualized approach that addresses problems one at a time.

“If somebody has sleep disturbances,” said French, “we teach them better sleep hygiene or they might get medication. If they’re having cognitive issues, it’s our responsibility to document what areas they’re having difficulty in and tailor a program so that they’re not doing things that would hamper their recovery. And then we follow up with people after they’ve been assessed. Even after they’ve left the hospital, we call them each week for 12 weeks, we call them again in six months, we call them in a year to make sure they’re doing okay. And we bring them back in for reassessment periodically to make sure they’re doing okay. We don’t want anyone out there in distress. We want to very proactively seek them out and make sure everyone is getting the treatment that they need.”

French entered a room occupied by Private First Class Jeffrey Sanders, a 22-year-old Marine from Millmont, Pennsylvania. French quietly asked Sanders to describe his ordeal.

With no embellishment, Sanders told of how an improvised explosive device exploded in the middle of his convoy on September 6, 2004, blowing him out of his Humvee and severing his left leg. He described those first few moments afterward – when he suddenly realized that he was lying in the road while the battle raged about him – as dreamy and surreal. “It was like the beginning of Saving Private Ryan,” Sanders said. “Everything was in slow motion.” Sanders soon snapped out of his stupor, tore off parts of his uniform, and used the cloth to control the bleeding from his leg until his comrades were able to get to him 15 minutes later. He waited another agonizing hour before getting morphine after being transported to an aid station in Baghdad, because the field medics had exhausted their supply on other injured men during the firefight.

French told Sanders that he was exhibiting some signs of brain injury and promised that further testing and treatment will be forthcoming. Sanders was clearly relieved; he realized that something wasn’t quite right, but hasn’t been able to figure out exactly what. “Sometimes I’m talking to somebody and I just forget what the conversation is about,” he confessed. The soldier’s gratitude toward French is genuine, and French promised to return soon.

Back outside the room, French took a deep breath and stared down the hallway for a moment. “This is very sad work,” he said with a rueful smile. “But as hard as it is, it’s not as hard as the work these soldiers have done for us. They’ve served their country, and been injured doing so. We owe them a lot. We owe them the best we can give them.” Ready to honor that debt in the best way he can, French strode down the hall to the next patient.