My desire to understand the so-called "signature wound" of the Iraq War — traumatic brain injury — and the uncounted casualties flowing from it all began with Marine Cpl. Jimmy Welter.

I met Welter in June 2005 in Ramadi, back when the provincial capital of Al Anbar Province in Iraq was marked by endless violence. He was among the U.S. Marines guarding the government center, which was under a permanent state of siege. No one strolled from an armored Humvee into the municipal building; they ran to deprive snipers of a static target. When official cars entered or left the compound, the Marines threw stun grenades to clear people away from the entrance gate.

At that time, journalists had just begun to report on the war’s traumatic brain injury. In USA Today, the newspaper where I work, we were the first to report that it was the phrase "signature wound" in a front-page story four months earlier. I had written that story after receiving a tip from a Department of Veterans Affairs official who had noticed a disturbing trend in traumatic brain injury among Iraq’s wounded veterans. For that story, I interviewed a pilot hurt in a helicopter crash and a Marine struck down by a mortar round. Both were carried off the battlefield on litters. But the more subtle — and, as it has turned out, far more common — mild traumatic brain injury was less understood. Victims could suffer this wound and walk away from the attack showing no outward signs of it. And how often this was happening was unknown.

Personal Testimony

That’s where Jimmy comes in. I was writing about the fatigue of multiple deployments when I met him. Jimmy was already on his third combat tour by the summer of 2005 and getting worn out. "I’m 22 years old. It really feels like I’m 30," he’d tell me. When I would patrol with him and other Marines through the narrow streets of Ramadi, they would talk about the roadside bombs. These were everywhere and exploded every week.

The Pentagon wasn’t generous with attack statistics back then, but we would learn later that in 2005 there were 20 to 30 roadside bomb attacks against U.S. forces in Iraq every day. That would more than double in a year. Even in 2005, the more devastating of these were buried deep in the ground — often a bundle of artillery rounds set off by a garage-door opener or cordless telephone from nearby. The blast could rip an armored Humvee apart and kill every Marine inside. Once back at base camp, other Marines in the same platoon, unhinged by the split-second destruction of their friends, would momentarily refuse to go out again. Chaplains had to soothe their fears.

More often the bombs were smaller. Insurgents would throw them onto the road in a rice sack or conceal them in garbage piles. These were not large enough to demolish a passing vehicle. But they could sometimes blow the doors open on an armored Humvee and flatten the tires, leaving the passengers inside stunned and oddly giddy for having survived. Jimmy would tell me about those "Come-to-Jesus" moments — the blast, the blinding flash, the instant pressure wave of displaced air, and the dust cloud. Marines would wag their heads, dizzy from the affects, and laugh or curse at each over the exhilaration of still being alive.

And there were always the headaches that would last for days. Jimmy — a tough, Irish kid from south of Chicago — would shake off the effects and keep going. Why show any more weakness than anyone else? No medical person was there to routinely check them for a concussion back then. If they weren’t bleeding, they were okay. Corpsmen and medics were not yet schooled about blast-induced brain injury.

But what Jimmy was telling me — and what I saw happening in and around Ramadi — made a lasting impression on me, especially so soon after I’d reported on this war’s signature wound. During interviews for that story, military doctors used the term "signature" because they saw something emblematic about this wound in this war. Roadside bombs were the insurgency’s most lethal weapon. With advances in body and vehicle armor, and medical evacuation and treatment, soldiers could survive these horrendous explosions only to emerge with a brain injury that could range from minor concussion to being left in a vegetative state.

Brain injury certainly existed in previous wars. But never before had so many soldiers and Marines survived after being so close to the epicenter of these explosions. The worst casualties were identified and treated. It was the more frequent and subtle cases of brain damage that were escaping diagnosis. And the science seemed fairly clear that back-to-back head injuries could mean even greater brain damage.

Had Jimmy or his fellow Marines suffered concussions? How many more were out there like him with these same experiences? How could they know if they were hurt? Who was there to tell them what, if any, lasting effects might result?

Professional Insight

When I returned from reporting in Iraq, I interviewed scientists at the Defense and Veterans Brain Injury Center in Washington, D.C.. There I learned they were already making progress in identifying these mild or moderate cases among the wounded arriving at Walter Reed Army Medical Center. These brain scientists said they shared my concern that there were soldiers or Marines who had finished their combat tours and come home with undiagnosed mild brain injuries.

In most cases, the damage was so subtle that it could not be seen on any brain imaging scan. So the scientists had developed a simple set of screening questions to be asked of returning troops. Were you exposed to a blast or other incident that could cause a head injury, such as a vehicle accident or a fall? Did you suffer any alteration of consciousness? Did you pass out afterward or feel dazed or confused? These screening questions had begun to be used at a few installations, such as the Marine Corps’ Camp Pendleton near San Diego and the Army’s Fort Bragg, North Carolina, and Fort Carson, Colorado.

In 2006, however, the Pentagon refused to give us all of the data uncovered from these screenings. From information we could obtain, we were able to piece together and report that between 10 percent and 20 percent of all the soldiers and Marines coming home to those installations from Iraq showed signs of having suffered at least a concussion or mild traumatic brain injury. Perhaps half were still suffering symptoms.

"This blast group is potentially huge," a Pentagon neuropsychologist based in San Diego told me. "We’re looking at thousands of potential patients."

By then, the Pentagon was under fire from within: Its own brain scientists and medical advisors wanted the department to develop a comprehensive system for diagnosing and treating these hidden wounds.

Telling This Story

At USA Today, we covered these developments as best we could. But it was difficult. My duties had changed from general assignment and occasional overseas war coverage to home-front reporting — focusing on the war’s impact here in this country with the people left behind. Though my new assignment offered greater license to write about traumatic brain injury, a host of other issues crowded my agenda. High on this list were the military’s mental health care services, the high rate of divorce in military families, and the war’s impact on children of the troops.

Another pitfall in covering the story was the arcane nature of new developments in understanding this signature wound. A lot of it was insider baseball for the neurological community: experimental drug treatments or imaging devices or scientific debates about minute variations in brain functioning. This was hardly the stuff that merits front-page coverage in a newspaper of general readership. USA Today is not, after all, a medical journal.

Still, when time permitted between my reporting on other stories, I uncovered a few comprehensible nuggets by sitting in on seminars and scientific conclaves on brain injury. I learned that:

  • Scientists at the Department of Veterans Affairs (VA) had discovered how subtle damage to the brain from a blast could affect otherwise healthy vision, making it difficult for the brain to focus both eyes at the same time. This could make the simple act of reading and comprehension tiring and frustrating.

  • A scientist at Johns Hopkins University Applied Physics Laboratory, with a history of traumatic brain injury research dating back to the Bosnian War, was making startling discoveries in animal studies. Dr. Ibolja Cernak presented her findings at a Washington seminar last fall suggesting that blast overpressure interrupts the metabolism of healthy brain cells, sending them into a self-destructive tailspin ending in cell death. Her results suggested there is a potential for long-term consequences.

By 2006, medics in the battlefield were finally being trained in how to recognize brain-injury symptoms. Clinical guidelines disseminated in the war zone laid out a diagnostic protocol for anyone exposed to a bomb blast — how to identify, diagnose and treat them. More military installations, as well as the VA, were screening troops and veterans from Iraq and Afghanistan for brain injury.

While it had always been possible for us to do some rough calculating and estimate, based on percentages, how many troops might have suffered this wound, by 2007 the military had some hard numbers. And we tried to find them. The process was painstaking as our requests met with resistance. One installation, the Army’s Fort Hood in Texas, gave up data only after we filed a Freedom of Information Act request. But by pulling together numbers from four military installations, the VA and an Army hospital in Germany — through which all wounded from Iraq and Afghanistan arrive from the battlefield — we reported last December that at least 20,000 troops had suffered this hidden wound in battle.

The official Pentagon tally of war wounded from Iraq and Afghanistan at that point stood at about 30,000. But the Pentagon ran its tally based only on troops who were identified as wounded in the battle zone. It did not include soldiers and Marines whose brain injury was not diagnosed until after they left Iraq or Afghanistan. These 20,000 cases of brain injury that we found were not included in the official casualty count.

A brain-injury consultant to the Pentagon conceded that the military needed to do "a better job of reflecting accurate data" in its casualty count. Early this year, researchers at the Rand Corporation published a study on the "invisible wounds of war" and, by doing some math based on percentages, estimated that potentially 320,000 veterans may have suffered traumatic brain injuries in Iraq and Afghanistan during the past seven years. Among them might be Jimmy. But who knows? He has long since left the Marine Corps. So much more remains to be learned, but the military doesn’t make the job easy.

Gregg Zoroya has covered the home-front beat for USA Today since 2005 and has worked as a reporter for the newspaper since 1997. He received a first place Headliner’s Award for beat coverage in 2006.

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