Traumatic Brain Injury: The Invisible Wound

July 15th, 2004 - by admin

Matthew B. Stannard / San Francisco Chronicle – 2004-07-15 09:32:28

(July 14, 2004) — Sgt. 1st Class Alec Giess clenched his eyes shut as he struggled to recall how his fellow Oregon National Guardsmen found him after a truck, swerving to avoid a suspected land mine, ejected him onto an Iraqi roadway — then rolled on top of him.

“If my boots weren’t sticking out from under the truck, they probably wouldn’t have found me. It was like the Wicked Witch of the East in …” He paused, his face a mask of concentration. “What is that? Oh, yeah, ‘The Wizard of Oz.’ ”

That effort to recall a film known and beloved by nearly every American is one Giess must bring to all his activities now, from remembering to eat lunch to arriving on time at his daughter’s middle school graduation.

Giess has more or less healed from many of the injuries he suffered when the transport truck landed on his body and gave him cracked vertebrae, a broken collarbone and shoulder and bruises where his life-saving body armor pressed into his skin.

But he still suffers from traumatic brain injury, or TBI, a wound that has proved unusually common in the Iraq conflict, in which new body armor saves soldiers from injuries that would have killed them in the past but can’t keep their brains from banging against the walls of their skulls.

Giess, who reaches his 45th birthday this month, is being treated at the Veterans Hospital in Palo Alto, home to one of just seven centers in the nation dedicated to researching and treating traumatic brain injury in veterans.

As Many as Two-thirds of Injured Troops Suffer from TBI
While experts say that perhaps 20 percent of injured veterans of past wars suffered from TBI, early estimates from screening at Walter Reed Army Medical Center in Washington, D.C., of injured troops returning from Iraq deemed at high risk for TBI suggest that, whatever their other wounds, as many as two-thirds also had brain injuries.

The numbers are still being studied, but several factors may be contributing to the increase, according to researchers. They say better medical technology and awareness may be leading doctors to look more carefully for signs of TBI. Researchers also blame modern warfare and the unique nature of the Iraq conflict.

Modern armor is strong enough to let a soldier shrug off a direct hit from a rifle round, and cutting-edge battlefield medicine is keeping more casualties from becoming fatalities. But the standard-issue helmet doesn’t guarantee protection against impacts that cause brain injury, and battlefield medics can do little to treat it.

And the weapons preferred by those attacking U.S. troops in Iraq — land mines, improvised explosives, mortars — deliver exactly the kind of concussive blast that can cause TBI, even if soldiers suffer no obvious external injury, researchers say.

The results can easily be overlooked, even by sophisticated medical tests. Soldiers have checked out of hospitals without knowing they had a brain injury.

“They were just sent home, and we found out only retrospectively that there were many, many problems,” said Henry Lew, medical director of the Palo Alto VA’s Comprehensive Rehabilitation Center.

The symptoms of traumatic brain injury — irritability, poor memory, disinhibition, anxiety and depression — can make day-to-day life a struggle. In severe cases, it can lead to inexplicable, violent confrontations with strangers or family members.

But unlike amputation, paralysis, burns or other physically disfiguring wounds of war, TBI’s scars and symptoms are subtle and all too easily dismissed as personality quirks or moodiness that seem natural after combat.

“TBI is a silent handicap,” Lew said. “If you met (a patient) on the street or in a bar or anywhere, you would never notice they had TBI.”

A Body Recovered; A Memory Erased
Take Army Spc. Rigoberto Oceguera, a 23-year-old Chico native now convalescing with Giess in Palo Alto. Without close inspection, little on his body betrays the fact that he barely survived plummeting hundreds of feet from the sky when his Chinook helicopter was shot down by a missile outside Fallujah in November.

The attack killed 16 soldiers and injured 26, including Oceguera. Today, his lungs are free of blood, his broken pelvis is healing, his eye is back in its socket, and healing scars hide where his spleen was removed. On the outside, he looks much like the young man who joined the Army with dreams of making its tae kwon do team, maybe turning military service into a career, with time out to compete in the Olympics.

“I can still kick,” he said proudly during a recent interview. “Yesterday was my first day to run. I ran around the hospital.”

But some problems haven’t gotten better. Oceguera, never a strong student, once harbored hopes for college. Now, he has even more trouble learning. And inside his head, he has other scars, other losses.

The last memory he has of his time in Iraq is watching the movie “Resident Evil” with some buddies sometime around Halloween. His next memory is of coming to his senses in a bed in Walter Reed.

“It felt like I fell asleep in Iraq, and I woke up in the States,” he said. “I didn’t know what had happened to me.”

Oceguera can’t recall the accident, which killed one of his Army buddies. He couldn’t recall the man’s name until he saw his face on a memorial Web site. He can’t remember the first time his family visited him in Walter Reed, when, his mother says, he seemed to think he was still in the war, maybe imprisoned. He can’t recall “President whatshisname … Bush” visiting Walter Reed in mid- December.

And he can’t recall re-enlisting, an event that occurred sometime between “Resident Evil” and the crash, but which Oceguera only discovered when he noticed that his identification card — with a photo of him in a coma — had a separation date three years later than the one he remembered.

“Weird” is the only word he can think of to explain how he feels.

Most symptoms of TBI are so subtle that it is often a family member who first detects a problem, Lew said. Giess’ wife, Shana, noticed after his return that the easygoing, relaxed dad who went to Iraq had become a quick- tempered man who couldn’t remember the family’s daily schedule, jumped up screaming when the family cat landed on his bed and couldn’t tolerate crowds.

The world inside his head, Giess said, was even stranger: He felt bewildered, with no sense of time other than “daytime” and “nighttime.” He also felt cut off from his emotions.

“When my kids come and hug me, I don’t feel a thing,” he said.

In retrospect, Shana Giess said, much of her husband’s behavior reminded her of the special needs children she works with as an educational assistant.

“When they finally diagnosed him, it all made sense,” she said.

After some errors he made filling out a standard military form brought him to the attention of a neurophysiologist, Giess was transferred to Palo Alto, where he has been trying to reconstruct his old self through a program that uses intensive scheduling and repetition to try to retrain the damaged mind.

“You teach yourself something, then the next day you’ve got to teach it again. And again. And again.” Giess said. “Remembering how to remember.”

As he spoke, he flipped through photographs of himself in Iraq, building schools, helping the people there rebuild lives lost to war and chaos. Next to him was a white binder — his “memory book” — containing his personal information, schedule and handwritten notes reminding him of … everything. Around his wrist was a rubber band reminding him to look in the book.

The memory book is one of a number of tools designed to help patients rebuild skills they need for a normal life. The center also has a kitchen and laundry where patients can drill in everyday chores. And there is a sophisticated, $89,000 driving simulator, a pilot project designed at Palo Alto, to help patients get ready for the road.

The center is also involved in research into traumatic brain injury, said Lew, including a recently launched large-scale study to see if Ritalin, usually used to treat attention-deficit disorder, also can help with TBI, which has many symptoms similar to ADD. Anti-depressant drugs and some other medications have also proved useful in treating the symptoms, he said.

Researchers also are looking at whether the next-generation military helmet can better protect against TBI and are teaching battlefield medics to carry out basic screening for brain injuries. Sometimes, just allowing a patient to rest a few days after a brain-rattling injury can prevent later problems, said Deborah Warden, national director of the Defense and Veterans Head Injury Program.

Still, the main thing healers can do for TBI patients right now is retrain them in life’s skills, Warden and Lew said, and teach them ways to work with the mental slowness and memory loss that will always be with them.

It helps, Giess said, but life is still hard. When he recently went home to attend his daughter’s middle school graduation, he had to contend not only with crowds of family and friends and a daughter who seemed to have gone from little girl to young woman overnight but also with his own baffling sense of time, which nearly made him miss his daughter’s big moment.

“When I got there, I wished I was here,” he said. “It was mind-boggling, all the activities.”

Life May Never Return to ‘Normal’
Shana Giess says she saw some improvement in her husband during that visit, but she worries about the future, about whether he can run his own construction business again when he can’t remember to make a haircut appointment.

“(My daughter) did ask me one day when is life going to get back to normal,” she said, tearfully. “And I said, this could be it.”

What frustrates her even more, she said, is how she feels her husband and those like him — those without obvious injuries, especially the ones whose wounds were not incurred in direct combat — sometimes are treated.

“It doesn’t make the news because they didn’t take a bullet,” she said. “They definitely get overlooked. It’s kind of like, you have a head injury, you’re in the loony bin. It can definitely be stigmatizing.”

It has also made it difficult for the advocates of brain-injury patients to get attention or funding, they say, even though some 5.3 million Americans are living with TBI-related disabilities, and about 1.5 million suffer a traumatic brain injury every year.

“This is one of the most underestimated problems in America today,” said Martin B. Foil Jr., a volunteer on the board of directors of the National Brain Injury Research, Treatment and Training Foundation.

The Palo Alto center is one of the seven national facilities funded by a $7 million program started after the Persian Gulf War in 1991. But with 350 veterans of the conflicts in Iraq and Afghanistan already being treated through the program nationwide, there is pressure to expand existing facilities like the one in Palo Alto, which has just 24 beds.

More Funds Requested to Treat Combat Head Injuries
In May, Foil asked the Senate Appropriations Committee’s defense subcommittee to add $7 million to the Pentagon’s 2005 health budget for the Defense and Veterans Head Injury Program.

“I don’t think you can hang a tag on what our soldiers are laying down for in Iraq,” he said. “How can you put a price tag on them? How can you put a price tag on a change in personality? How can you put a price tag on a loss of memory and your ability to support your family?”

Warden says the most crucial needs now are outpatient care and remote facilities so patients can be treated outside the center.

Florida Democratic Sen. Bob Graham has introduced legislation proposing a Department of Veterans Affairs War-Related Blast Injury Center dedicated to researching injuries such as TBI.

In the meantime, Lew and the other doctors in Palo Alto say they are trying to be advocates for their patients as well as healers and researchers.

Oceguera, for one, hasn’t given up. He went into the Army with big dreams, and he still has them — though instead of going to the Olympics himself, he now hopes to train his 11-year-old sister to go in his place.

“Bad stuff happens to me, and I come back,” he said. “My philosophy is the smartest person in the world isn’t necessarily the best person in the world.”

His mother, Sylvia Oceguera, has some hope too. She didn’t at first. When her boy came back from Iraq, he was quick to anger — especially quick, it seemed, at her — and didn’t want to stay at her home. But on July 4, she said, he surprised her with a visit and a bouquet of flowers.

It’s going to take time, she says. But she believes her son will come home.

“You gotta listen. … Give all your love. That’s the main thing,” she said. “Just give them all your love and try to understand. It’s hard. It’s really hard.”

Symptoms of traumatic brain injury

These are some of the common symptoms experienced after a brain injury. Veterans or their family members with questions about TBI can contact their local Veterans Affairs hospital or the Defense and Veterans Brain Injury Center at (800) 870-9244 or

Persistent headaches

• Difficulty remembering

• Trouble concentrating

• Feeling unusually tired

• Changes in sleep

• Mood changes

• Ringing in the ears

• Confusion

• Irritability

Source: Veterans Affairs Palo Alto Health Care System

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E-mail Matthew B. Stannard at