The explosive device detonated without warning, in a fireball that seemed to erupt in slow motion. Army Pfc. Robert Bartlett could count the rocks and shrapnel drifting toward him over the hood of his Humvee. Then he felt a sledgehammer slam into his face. In unbearable pain, he went blind. Through the ringing in his ears came faint screaming - his own. The soldier beside him was killed instantly. The turret gunner above Bartlett collapsed on his shredded and charred legs and the two men clutched each other in pain and terror.
The blast tore into Bartlett's face, perforated internal organs and collapsed a lung. A bear of a man, Bartlett was dragged out of the kill zone, eventually ending up under the care of surgeons at Johns Hopkins Hospital in Baltimore.
Blast from improvised explosive devices, or IEDs, is the enduring agony of the American experience in Iraq and Afghanistan, an ancient weapon brought to terrifying lethality.
It has killed 2,400 Americans, who are among those who will be remembered on this Memorial Day as overseas wars continue to unfold.
It has also left 23,000 wounded, many so severely that they will require lifelong intense medical and psychological care.
Many more, medical officials say perhaps tens of thousands, have returned from long deployments under constant threat of or exposure to blast, bearing mental scars and brain trauma about which little is known.
"Blast injury will be the defining long-term medical burden of this conflict," said a Navy combat surgeon in Afghanistan, who asked not to be identified for personal security reasons.
Bartlett and others agreed to talk about their experiences to deepen the public's understanding of what troops face in the war zone, and to share their pride of service.
The Arizona native who is rehabilitating at the Walter Reed Army Medical Center served as an Army scout-sniper. But until he was injured four years ago, he spent most of his time in Iraq on humanitarian missions.
"It was, hands down, the best thing I have ever done in my entire life," he says. "I will never complain, ever again."
IED blasts cause a ghastly array of wounds. The shock wave can rupture lungs, eardrums and even eyeballs, shear tissue and shatter bone. Victims are often smashed against steel wreckage, and dirt and metal fragments are driven into their bodies. The flesh on Bartlett's face and hands was burned away and he lost his left eye.
Those like Bartlett who survive suffer severe, multiple wounds that together are beyond the scope of ordinary medicine.
To meet the avalanche of IED survivors, the Department of Veterans Affairs has expanded a small "polytrauma" program originally designed for car wreck victims into a national network of four major polytrauma hospitals and 21 regional centers that specialize in the challenges of the grievously wounded
In one typical case, described by Dr. Shane McNamee, medical director at the Richmond, Va., polytrauma center, a soldier arrived having barely survived an IED attack.
The blast had torn off both legs, severely injured one arm and shattered his pelvis into 60 or 80 fragments.
He had bled so badly his blood had been replaced five times. His possible brain damage due to lack of oxygen and a spinal cord injury had destroyed his lower-limb muscular control, meaning he could not wear prosthetics.
He was severely disoriented, often waking up screaming. His wounds had become infected.
He was 22 years old.
"One of the most gruesome things I've seen in medicine," McNamee said in an interview. "How do you fix a guy like that?"
It takes a large staff and intensive care. For 12 inpatient cases, McNamee directs a staff of 36 nurses, three physicians, three mental health specialists, a psychologist, four physical and occupational therapists, pain management experts, a dietitian, a wound specialist and others - some 60 people in all.
Treatment is specialized, and innovative. When the patient's wife gave birth, they moved mother and baby into his room.
After two years he was moved home, attended by full-time caregivers and therapists. He can dress himself and feed himself. His family declined to be interviewed.
"But it's not good, just getting around at home, getting a pat on the back," said Dr. David Cifu, chief of physical medicine and rehabilitation service at the Richmond polytrauma center. "America just isn't set up to get handicapped people back to work."
Even for veterans without visible wounds, the searing experience of combat, the constant threat of IEDs and the often jarring return to "normal" life produce readjustment problems that often can be solved with family support and what some mental health experts refer to as "beer-sex-sleep-pizza" therapy.
IED blast survivors have a wider range of mental health challenges. Most, like Bartlett, suffer from post-traumatic stress disorder.
Depression is common; blast victims often experience damage to their brain's frontal lobe, making them "more susceptible to depression - a lifetime risk," said McNamee.
For others, damage is less visible and not well understood. Some 40 percent of troops returning from Afghanistan have experienced at least one IED blast at close range, according to a survey by the U.S. Army Mental Health Advisory Team.
Living under daily threat of IED blast takes a toll as well, said Dr. Sonja V. Batten, a clinical psychologist and senior mental health expert at the VA in Silver Spring. Two-thirds of the troops serving in Afghanistan work in areas where IEDs have exploded; 40 percent said an IED had exploded near them, according to a U.S. Army mental health report.
Troops exposed to IEDs over a typical 12-month deployment are more likely to have "significant long-term adjustment problems than people exposed to one or two IED blasts," Batten said in an interview.
But she stressed: "The science is very new; there is still a lot more we need to learn" about the mechanisms of mental injury and how to treat it.
For Bartlett, 35, psychological therapy included plunging into the world of veterans' self-help, working with groups like Healing Waters, a national, nonprofit organization that takes wounded veterans fly fishing.
"Guy said to me the other day, 'How can I stand in a river? I got no legs!' He's a quadriplegic. He can move his arms a bit. He goes out there and fishes. We got a blind guy, he fishes."
"It's important that we look after one another. Nobody knows our pain more than each other," Bartlett said.
"My first steps out into the world with half a face, I was drooling, my jaw was wired shut, I couldn't talk. People couldn't help but stare, and I couldn't give them a smile back. How do you focus on the positive?
"Being able to walk again, talk again," he answered. "You count your blessings every step you take."
Monday, May 25, 2009
From The Baltimore Sun. In the picture, veteran Robert Bartlett (shown in another veteran's wheelchair, although Bartlett doesn't use a wheelchair himself) was wounded by an IED blast in Iraq four years ago.
Posted by BA Haller at 5:25 PM