Losing their minds
More U.S. soldiers than ever are sustaining serious brain injuries in Iraq. But a significant number of them are being misdiagnosed, forced to wait for treatment or even being called liars by the Army. By Mark Benjamin. Salon.com
Jan. 05, 2006 | After fighting in heavy combat during the initial invasion of Iraq, Spc. James Wilson reenlisted for a second tour of duty. Now 24 years old, he loved the life of a soldier.
In the fall of 2004, his 1st Cavalry Division was mostly fighting in Sadr City, a volatile sector of Baghdad. On Sept. 6, Wilson was manning a .50-caliber machine gun atop a Humvee when a bomb or bombs went off directly under the vehicle, rocking his head forward and slamming it into the machine gun. A fellow soldier told Wilson that his Kevlar helmet had been split open by the impact. The heat from one blast felt like “a hair dryer” on his skin, multiplied “times 20,” Wilson later wrote in his diary. To the best of his recollection, the force of the blast also knocked the gun from its mount, smashing it into his leg.
Although battered in the attack, Wilson didn’t appear badly hurt — on the outside, at least. But in the days that followed, the young soldier from Albany, Ga., says he often felt “really dizzy, lightheaded and dazed.” Two weeks after the battle, Army medics felt Wilson was suffering from post-traumatic stress disorder and evacuated him out of Iraq for medical evaluation. Wilson was first flown to Landstuhl Regional Medical Center in Germany, where wounded troops are stabilized, and then sent to Walter Reed Army Medical Center in Washington, D.C., in October 2004.
After arriving at Walter Reed, Wilson repeatedly told doctors that he had experienced a hard blow to the head during combat in Iraq. He suffered from symptoms strongly associated with a traumatic brain injury, which occurs when the brain is rocked violently inside the skull, tearing nerve fibers: seizures, short-term memory loss, severe headaches with eye pain, and dizzy spells that have made him vomit. During a visit to the Pentagon around Christmas 2004, Wilson got so dizzy he vomited “all over” the carpet while meeting Deputy Secretary of Defense Paul Wolfowitz in his office.
Despite Wilson’s description of his injury and his symptoms, Walter Reed officials repeatedly questioned his mental state and the authenticity of his combat story. In a June 2005 memorandum from an Army Physical Evaluation Board, some Walter Reed doctors stated that Wilson exhibited “conversion disorder with symptoms of traumatic brain injury.” Conversion disorder holds that symptoms such as seizures arise from a psychological conflict rather than a physical disorder. Col. James F. Babbitt, president of the Physical Evaluation Board, accused Wilson of being a liar. “I believe that the preponderance of the evidence available to the Board supports an alternative diagnosis … one of malingering,” Babbitt wrote in that memo.
Wilson and his wife, Heidi, who has been staying with him at the hospital, vigorously fought the psychological diagnosis and furiously sought medical treatment. The malingering charge was especially painful. “I want my dignity, pride and respect back,” Wilson says. After serving his country, being accused of misleading doctors, he says, “is the worst thing in the world.”
Today, Wilson is thin and has a shaved head. He often clenches his eyes shut, as if to squeeze at the pain in his skull, or search out an elusive word or memory. Whenever a dim detail of his combat duty bubbles up in his mind, he types it into his diary. He holds his hands awkwardly, with his thumbs folded over his palms. His speech is at times slow and slurred. “I have been dealing with this all year because no one would help me,” he says.
On Dec. 19, 2005, more than a year after he was admitted, Walter Reed finally sent Wilson to a neurological center to be treated for traumatic brain injury. Neuropsychological testing done at Walter Reed on Oct. 11, 2005, led officials to conclude that “there was no indication of malingering.” According to a neurosurgeon with extensive experience treating combat head injuries, an October 2004 MRI of Wilson, combined with a description of his symptoms, showed that he should have been treated for a traumatic brain injury right then. Medical experts say the failure to treat a brain-injury victim promptly could hinder recovery.
Spc. Wilson is not alone among Iraq veterans who have been misdiagnosed or waited for treatment for traumatic brain injury. Other soldiers interviewed at Walter Reed with apparent brain injuries say they too have been deeply frustrated by delays in getting adequately diagnosed and treated. The soldiers say doctors have caused them anguish by suggesting that their problems might stem from other causes, including mental illness or hereditary disease. According to interviews with military doctors and medical records obtained by Salon, brain-injury cases are overloading Walter Reed. As a result, a significant number of brain-injury patients are falling through the cracks from a lack of resources, know-how, and even blatant neglect.
Exactly how many brain-injured patients are being missed, going without care, or left waiting, as opposed to those who get prompt, top-shelf treatment, is difficult to say. Walter Reed officials and doctors say the Army is getting better at treating brain-injured patients but admit cases like Wilson’s are a significant problem.
A November 2003 report from the Army News Service states that because brain injuries aren’t always obvious, they “may be neglected, or even pushed aside as merely psychological.” Patients with traumatic brain injuries “are suffering as much, but may not get the same support as someone who has an observable injury like a bullet wound or a broken leg,” says Dr. Louis French, a neuropsychologist at Walter Reed, in the article.
One thing is certain: Due to today’s military technology and insurgent tactics in the Iraq war, more U.S. soldiers than ever before are sustaining and surviving serious head injuries. In fact, traumatic brain injuries are a major problem among soldiers arriving at Walter Reed. According to the hospital’s brain injury center, 31 percent of battle-injured soldiers admitted between January 2003 and April 2005 — 433 patients — had traumatic brain injuries. Half of those had what the hospital calls a “moderate, severe or penetrating brain injury.”
In past wars, brain-trauma rates among combat casualties hovered around 20 percent, according to the Army. The rate of brain injuries among troops wounded in Iraq has shot much higher because the bomb, rather than the bullet, is the weapon of choice for insurgents. In addition, today’s better body armor and helmets save soldiers’ lives in explosions that would have otherwise killed them.
Through a spokesperson, Walter Reed and other Army officials, including Col. Babbitt, who accused Wilson of malingering, declined to be interviewed. “We cannot discuss specific cases with anyone except the Soldier due to the Privacy Act and HIPAA [the Health Insurance Portability and Accountability Act], nor could we address the case or responsibilities of the president of the [Physical Evaluation Board] without violating some portion of HIPAA,” wrote Lt. Col. Kevin V. Arata, an Army public affairs officer, in an e-mail. “Therefore, I cannot arrange an interview.”
But according to a written statement that hospital officials provided to Salon, Walter Reed does have a plan to identify and treat brain-trauma patients. The military has a network of eight brain-injury rehabilitation programs under the rubric of the Defense and Veterans Brain Injury Center.
The program was created in 1992 to prevent brain-injured soldiers from being misdiagnosed as mentally ill, or missing treatment completely. Some brain injury patients get treatment from neurologists or neurosurgeons; others get treatment from physical, occupational and speech-language therapists. The hospital says it screens for brain trauma all patients who arrive at the hospital who were injured in blasts, vehicle wrecks or falls, or who have obvious, penetrating head wounds.
There are many success stories, says John DaVanzo, clinical director at Virginia Neurocare, a rehabilitation center in Charlottesville, Va., where Wilson is receiving treatment. “Yes, there are soldiers being missed,” DaVanzo admits, but many others with brain injuries, who would’ve been overlooked in past wars, are being identified and treated. Still, working in partnership with Walter Reed, DaVanzo has seen the strain on the system during the Iraq war. “There is a massive influx of injured soldiers,” he says. “People are overworked.”
Walter Reed hospital is renowned for state-of-the-art technology and certain kinds of care. One Walter Reed physician tells Salon that the care for amputees at the hospital is “amazing,” and praises the work of colleagues, adding that the nurses “work their butts off.” However, the physician is worried that a distressing number of patients at the hospital with brain injuries aren’t getting adequate screening and care, and says many doctors at the hospital know little about brain injuries and are prone to making a wrong diagnosis.
“A lot of things are missed because the doctors are swamped,” the physician says. Many military doctors are away serving in Iraq or Afghanistan, and some patients are forced to wait too long for surgeries they need. “We’re overwhelmed in terms of resources,” the physician says. (Salon agreed to withhold the identity of the physician, who was not authorized to speak to the media, and feared retribution from the hospital.)
The delay in proper diagnosis and treatment for Wilson and others with apparent brain injuries is particularly troubling because patients tend to benefit from a prompt response. An April 13, 2005, article about brain trauma from the Department of Defense’s own press service says that “if the injury is detected and treated early, most victims can recover full brain function, or at least return to relatively normal lives.”
Traumatic brain injury can come from a car wreck, or when the sudden pressure from shock waves from an explosion collide with the fluid-filled cavity around the brain. Diagnosis can be tricky because the memory loss, personality change or depression that can accompany traumatic brain injury can also mimic other combat injuries connected with mental health, including post-traumatic stress disorder.
But Dr. Gene Bolles, a former chief of neurosurgery at Landstuhl Regional Medical Center in Germany, says it is plain wrong to place the burden of proof on wounded soldiers. Soldiers coming out of combat who say they’ve suffered a head blow and who show symptoms of traumatic brain injury should be treated for it, says Bolles. “You do what you can for them,” he says flatly. “You believe them.”
Bolles reviewed a summary of Wilson’s October 2004 MRI from Walter Reed. He says it showed “evidence of loss of blood supply” to the brain and was “compatible with a head injury.” Alongside Wilson’s story and symptoms, he says, “This sounds like typical head injury syndrome to me; you can make that diagnosis.”
He notes that the “shearing effect” on nerve tissue that comes with a serious head blow can be invisible to MRIs and CAT scans and that “there are no definitive tests that prove this syndrome.” But soldiers even remotely suspected of having a brain injury, he says, should be treated aggressively for it, rather than with skepticism.
Bolles, who now practices at Denver Health Medical Center, treated U.S. soldiers evacuated from Iraq and Afghanistan for two years at Landstuhl. While many soldiers get good treatment, in other cases “the system is kind of like you have to prove yourself with an injury before anyone believes you,” he says. “I wish we would accept the word of a patient if a patient says, ‘This is what I’m feeling,’ rather than trying to prove somebody is malingering.” It is better to treat soldiers for what they say is wrong with them, he says, even if that means a few cheaters get through the system.
Annette McLeod says her husband, Spc. Wendell McLeod Jr., was belatedly diagnosed with a traumatic brain injury. McLeod landed at Walter Reed in August after being hit by a truck in Iraq but was not diagnosed with a brain injury until December. “If you come in and are missing a limb, they know how to handle you,” says Annette McLeod. “Anybody with injuries you can’t see is shoved to the side.”
McLeod says that to her knowledge her husband, Wendell, was not initially screened for brain injury, even though he’d been hit by a truck. But his behavior was so erratic and his memory was so horrible, she says, that she badgered doctors until they ran some tests that identified his problem. “I knew there was something wrong because of the changes in him,” she says. “He kept saying, ‘I can’t remember. I can’t remember.’ This is a man who used to remember everything.”
McLeod, 40, arrived at Walter Reed last August with a fractured vertebra, a chipped vertebra, four herniated discs in his back, and a shoulder injury. He also began suffering from bizarre mood swings. “I can’t hardly remember anything,” he says. Annette, who is staying with him at Walter Reed, took McLeod to the supermarket recently. “He walked down the aisle three times and could not remember what I asked him to get,” she says. She makes her husband sit in the back seat of the car because ever since his accident he wildly grabs at the steering wheel.
McLeod was tested for traumatic brain injury in September but did not hear anything about the results until he was diagnosed in the first week of December. In the meantime, McLeod was told by officials that he might have been born with his brain problem. “They tried to say it was inherited,” McLeod says. Annette says they were also told it could be psychological. The misdiagnosis and delays have been excruciating, she says angrily, with a lot of “just waiting around and waiting around and waiting around.”
Sgt. Steve Cobb, age 46, tells a similar story. Injured in an armored personnel carrier accident in Iraq in 2004 while serving with the West Virginia National Guard, a head blow left him with short-term memory loss, hearing loss and the loss of peripheral vision in his left eye. He slurs his words and is so dizzy that he walks with a cane. Medics in Iraq first missed his brain problem completely and gave him aspirin. He served another eight months after the accident.
Cobb arrived at Walter Reed last May. In July, he was diagnosed with traumatic brain injury, but did not start getting therapy until September. He says that he, too, was told by hospital officials that he may have been born with his problem. “They said it was hereditary,” Cobb says with disgust.
His memory is so bad that his wife, Natalie, is afraid he can’t take care of himself. She has left her 13- and 19-year-old kids at home with family in West Virginia to be with her husband at Walter Reed. “We heard it was brain disease. We heard it was hereditary,” she says over dinner one evening at a restaurant near the hospital. “I feel that they are letting the traumatic brain-injury patients slide through the cracks.”
The stress of being misdiagnosed can further harm soldiers, says Bolles, the neurosurgeon, especially if patients get stuck in a pattern where doctors are denying that their injuries exist. “That in and of itself becomes a disability to these people if they get angry and frustrated,” Bolles says. “That alone makes it worth treating these people early.”
Wilson came back from Iraq a totally different man, according to his wife Heidi. In a photo of the couple from before his injury, the two are sitting on the edge of a fountain. Wilson stares squarely at the camera with a deft, slight smile. Heidi, in a white dress, sits in his lap, holding a bouquet.
Wilson’s injury has left him so sensitive to light that his room at Malogne House, a residential facility behind the main hospital at Walter Reed, looks cavelike, lighted only by two dim bulbs. Looking at bright light, Wilson says, “is like welding without your mask on.” Sometimes even the dim bulbs are too much. “It kills him,” Heidi says one evening in the room. “He puts little blankets over them.” Heidi says her husband’s brow turns a deep red during his worst headaches, which he says feels like his eyes are being sucked back into his skull. “I just want to take a drill and drill into my head,” he says.
Sometimes Wilson remembers events from long ago, but not what happened five minutes ago. He still writes bits in his diary, attempting to piece his memory back together. He used to enjoy cooking Cajun food but now that’s gone. “Everything tastes like rubber,” he says. “I look at stuff I want to taste. I feel like I remember what it tastes like, but I can’t.” When Heidi is away for a few days, his memory loss and olfactory problems collide, though he tries to keep a sense of humor about it. “If she is away, I may not take a bath for six days, until she gets back,” he says. Heidi nods vigorously. “I’ll get his bath ready and say, ‘Time to get in the tub,'” she says.
But when the conversation returns to Wilson’s treatment, their smiles quickly fade. It’s hard for them to believe, after two hard tours of duty, that this is the kind of treatment he has received. “I just want to be taken care of,” he says. “I just want healthcare.”