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July 15, 2005

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Publication Date: Friday, July 15, 2005

Reentry tough for injured vets Reentry tough for injured vets (July 15, 2005)

Wounds from Iraq war will forever change lives of young soldiers

By Diana Reynolds Roome

A field trip to downtown Mountain View can be a big event for an injured serviceman.

Some of these Iraq War veterans are venturing back out for the first time, usually accompanied by a recreational therapist, after months of rigorous rehabilitation in the Traumatic Brain Injury and Comprehensive Rehabilitation Unit -- a wing of the VA Palo Alto Health Care Center where vets with brain injuries go to convalesce.

This exercise can take almost as much courage as fighting in the Middle East. These vets, from the Navy, Army, Air Force and Marines, may not always look hurt because their brain injuries may be internal and invisible, but the damage is very real. Some need to learn all over again how to cross a road safely or count out the right money for a cup of coffee. Out in public

Combat injuries come in many forms, and other vets bear the wounds for all to see.

Jason Poole, 22, a Marine from Cupertino, was in Syria on his third tour of duty when an explosion blasted the left side of his face, sending shrapnel through his ear and eye. It shattered the roof of his mouth and nose and emerged on the other side of his face under his right eye. Poole was unconscious for two months at Bethesda Hospital in Maryland. Later, after reconstructive surgery to his mouth, his jaw was wired shut for two weeks.

Even now, exactly a year later, shrapnel speckles the tattoo on his large left biceps, and two huge scars run down his right arm. The scar from a tracheotomy tube, necessary to save his life, punctures his throat.

Poole has been making excellent progress and is able to go out independently now, or with friends and family. He wears sunglasses and a hat to cover the area where his head was shaved for a recent operation to reconstruct the side of his skull above the injured ear.

He doesn't feel secure about his injuries and is often embarrassed, especially when people react thoughtlessly.

"I'm just walking down the street and these guys say, 'Hey, what happened to you? You look jacked up,'" Poole recalls of a recent experience. Instead of walking on, he stopped and explained. His questioners were impressed and contrite. But Poole, who used to be an extrovert, finds himself shying away from people and has to force himself to make contact.

"I was always loud and laughing -- up until now," said Poole, whose three-times-a-week sessions with a speech therapist have helped him regain a strong, clear voice despite his jaw injuries. If people are curious about his looks, he said, it's best for them to ask rather than simply staring. He talks to everyone who will listen, and thinks it's fine if people ask, "What happened to you?" Modern war trauma

What has happened to Poole and many others is known as polytrauma, or the complex injuries that are typical of modern warfare in Iraq and Afghanistan, says Stephanie Alvarez, nurse manager for the Traumatic Brain Injury Unit at the VA Hospital.

Victims may be in wheelchairs, paralyzed from a brain or spinal cord injury or with amputations. Others are wearing helmets to protect areas of their skulls that have been shattered. Concussion, coma and oxygen deprivation have sometimes caused brain-cells to die.

Marine Angel Gomez, 19, was injured four months ago in Iraq and now sits in a wheelchair, with a helmet covering his head and his right arm barely able to move. He joined the Marines right out of high school and this was his second tour of duty in Iraq.

Gomez speaks mainly in monosyllables due to injuries to his left brain and frontal lobe, but his visiting girlfriend and family, who recently moved from Southern California to an apartment in Mountain View to be near him, help him find the words. He is working hard and making steady progress learning to walk, read single words, and follow map directions, though it may take longer to adjust emotionally to his new limitations.

Sometimes the best way to practice speech, said his father Paulino Gomez, is to remember songs he learned in childhood. Invisible damage

Other vets have no visible injuries but they may be suffering from TBI or traumatic brain injury, which results when they are caught in the vicinity of an explosion. Jarring vibrations can cause swelling or scarring of the brain. MRI and CT scans (also called CAT scans), which normally detect physical injuries, may fail to pick up any signs of damage, but the trauma becomes evident when these vets fail to function normally after weeks back home.

"They're physically able but they don't have the mental capacity to do things or speak for themselves," said Alvarez. "They can only focus on one thing at a time, they get easily overwhelmed and agitated."

Families call the rehab unit complaining that the person they reunited with is not the person they once knew. The vet may act out, overreact, suffer debilitating depression or fail to take responsibility for his actions. Some have post-traumatic amnesia. One young woman could not remember her experiences in Iraq and also forgot to feed her 11-month old baby.

Such serious problems used to be considered "adjustment disorders," and they are still under-diagnosed, caregivers say, even though the subtle damage -- which often only shows up after they have returned to the U.S. -- is now being recognized by doctors as genuine combat injury. Stages of recovery

The patients who end up in rehab at the VA have already been through several stages of recovery, first in Baghdad or Germany for emergency treatment, then at a military or naval hospital in Washington or Florida for surgery and treatment of acute injuries. Finally, they are brought across the country to California to relearn the skills necessary for everyday life.

They arrive, says Alvarez, "with pajamas and their records, that's it. ...One of our first admission criteria is that they can follow a one-step command. It would be defeating the purpose if they cannot remember what they learned and carry it over into everyday life."

One of the first steps is to dress the injured vets in everyday street clothes, then to establish routines. Nurses help them write reminders in bright letters on outsized calendars.

Brain-injured servicemen, many of whom are in their late teens and early 20s, need to return to basics, learning to take care of their personal hygiene, eat their meals on time, turn up for their appointments with the physical therapist, occupational therapist and neuropsychologist.

"They are reduced to toddlers again just as they gained independence," said Alvarez, who recently moved with her family, including two sons ages 3 and 5, to Mountain View. "Many are not aware of their deficits -- all they want is autonomy. But they need constant reminders to wash their face or brush their teeth. They may need to retrain their bowels and bladder. They could be disoriented and try to walk away."

Field trips to Mountain View or Palo Alto only come when they are considered advanced enough to start taking small steps towards independence.

"We want them to get used to people looking at them," said Alvarez. "It's best to talk to them in simple, short sentences, but otherwise to treat them normally." Patience is a virtue in this regard, as their math skills may be back to a 2nd-grade level, and some lack inhibitions and say whatever comes into their head, Alvarez says. Help from loved ones

Families are essential to the vets' healing, and many family members must go out of their way to return frequently to the Bay Area -- or temporarily move here -- despite the high cost of living and travel.

Several hotel chains offer low-rate rooms for veterans' families, and organizations like the Oppenheimer Foundation have donated money to help families stay close by. Last month, ground was broken on the campus of the Palo Alto VA for the Fisher House, which features 21 suites to accommodate families of injured servicemen and servicewomen.

Meanwhile, Paulino Gomez, Angel's father, is looking for a job in landscaping so he and his family can stay near his son.

"I am very proud of him," he said in Spanish, as Angel's girlfriend Jackie Moreno translated. "I want to give him words of encouragement, help him remember things, massage his arm and help him learn how to move it, and tell him always to stay on top and never fall back. I want always to be here for him."

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