IMAGE: Bryan Malone, Sara Granberry
Mark Humphrey  /  ASSOCIATED PRESS
Bryan Malone, 22, an Army specialist from Haughton, La., was injured during a rocket attack in Baghdad. He works with speech pathologist Sara Granberry at Vanderbilt Medical Center in Nashville, Tenn.
updated 9/9/2007 1:19:29 PM ET 2007-09-09T17:19:29

“I went home — R&R for 10 days — and the day I got back is the day I got hit,” Bryan Malone said.

“It was two weeks, you moron. It was 15 days,” scolded his friend, Eric O’Brien, adding to others: “The problem with him is, he’s as dumb as a box of rocks to begin with. We’ve got no baseline on him.”

Their jokes and sarcasm mask a serious worry.

These guys forget names, directions, appointments, where they put their keys, what they need at the store — things that are innocent memory lapses when they occasionally happen to normal people.

But their minds do not work like most people’s minds do. Not since an explosion rewired their circuitry and left them with the “silent epidemic” of the Iraq war — traumatic brain injury, or TBI.

Several thousand troops have been treated for it, and thousands more are believed to be suffering undiagnosed.

As more young men and women return from the war, TBI is a growing burden — for them, for the too-few doctors and programs available to treat them, and for taxpayers, who pay for their care and disability if they cannot hold jobs or make their way in the world.

Memory improves, emotional trauma starts
People with TBI have frequent headaches, dizziness, trouble concentrating and sleeping; are depressed, irritable and confused, and may be easily provoked or distracted. Speech or vision also can be impaired. The brain

Many symptoms overlap with those of post-traumatic stress disorder, or PTSD. Odd as it may seem, brain injury sometimes protects against PTSD by blurring awareness of what happened. But as memory improves, emotional problems can emerge: One of the first “graduates” of Vanderbilt University’s brain injury rehabilitation program committed suicide three weeks later.

“Of all the ones here, he would not have been the one we would have thought,” said the program’s director, Sandy Schneider. “They called him the Michelangelo of Fort Campbell” — a guy who had plans to go to art school, she said.

Some brain injury sufferers have been misdiagnosed with personality disorders. Others have lost jobs because of unrecognized and untreated symptoms.

“It’s the so-called invisible injury. It’s where a troop takes 10 times the normal time to pack his rucksack ... a complicated injury to the most complicated part of the body,” said Dr. Alisa Gean, a neurosurgeon at the University of California, San Francisco.

IMAGE: Eric O'Brien, Jenny Owens
Mark Humphrey  /  AP
Eric O'Brien, 32, an Army staff sergeant, tries to remember tasks he needs to perform as he prepares to take a walk with occupational therapist Jenny Owens at Vanderbilt Medical Center in Nashville, Tenn.

Most TBIs are mild, and most recover within a year. But one-fifth of troops with these mild injuries will have prolonged or lifelong symptoms and need continuing medical care, the military estimates. Nearly all of the moderate and severe ones will, too.

Diagnosing TBI is imprecise — damage rarely shows up on CAT scans or other tests. Treating it is a crapshoot, because little is known about the brain injuries from blasts in Iraq versus the ones from falls and car crashes that doctors are used to seeing.

“I’ve been in the field for 20-plus years dealing with TBI. I have a very experienced staff. And they’re saying to me, ’We’re seeing things we’ve never seen before,”’ Schneider said.

The usual approach is to work on specific symptoms and deficits — headaches, anxiety, vision problems, attention span — rather than try to cure the injury itself, since no one really knows how to do that.

But many troops with mild TBIs do not get care. Malone and O’Brien feel lucky to have had other wounds. Otherwise, government and private doctors say, they may have been sent back to fight with their brain injuries undetected.

Many injuries not obvious
“It’s hard to get treatment unless you get hurt,” Malone said.

“I had no antibiotics, no pain medication or anything. They just sent me on my way,” O’Brien said.

Malone’s brain injury was obvious. O’Brien’s took longer to be noticed even though it happened at the same time. O’Brien, a 32-year-old Army staff sergeant from Iowa’s Quad Cities, was teasing Malone, 22, a specialist from Haughton, La., in a Baghdad gym last summer.

“I told him and his workout partner: ’Put some more weight on it,” and they got up. Seconds later, a rocket hit where they had sat. They survived, but a pressure wave from the blast coursed through their brains.

“I patted myself down head to toe, making sure I wasn’t missing a limb,” and felt odd, like “I must be missing a chunk of my head,”’ O’Brien said. A guy yelled, “I’m hit,” and O’Brien saw him covered in blood. He remembers little else except walking through debris to pick up his iPod and sunglasses.

A ceiling air conditioning vent had fallen on Malone’s head and he had shrapnel wounds.

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“I remember coming to and thinking: Why was it so bright, and why was it so sandy, with all the light coming through the roof?” Malone said.

He had multiple surgeries, spent several months in Walter Reed Army Medical Center, and now has titanium mesh reinforcing the back of his skull.

O’Brien, however, had shrapnel removed from his scalp and was sent back to his unit. When he later complained of pain, doctors gave him Motrin. When he discovered a trickle of blood from his hip, they said he would be fine. Six weeks later, when he could barely walk, tests revealed shrapnel in his hip. By then, he was having headaches and trouble sleeping.

O’Brien had been through multiple previous explosions — on average, troops in Iraq experience one a month, one study found — and each blast raises the risk that the next one will do harm. Troops are proud and reluctant to go “off mission” just because “they get their bell rung,” said Dr. Michael Kilpatrick, a top Defense Department physician.

“Most of the treatment is explaining the situation and giving the tincture of time — giving it time to heal,” he said. If no big symptoms appear in eight to 12 hours, “they’re probably ready to go back.”

Pressure to return to duty
Officers also face pressure to return troops to duty, said Jordan Grafman, a neuroscientist who studies TBI at the National Institutes of Health.

“People don’t want to lose these guys from their command — they can’t replace them fast enough,” he said.

During a surprise visit to Iraq with President Bush on Labor Day, Gen. Peter Pace, chairman of the Joint Chiefs of Staff, said the military was “much smarter about this now,” and urged troops to watch for signs of TBI and post-traumatic stress.

“They are every bit as much battle injuries as is a bullet or shrapnel. It is OK, it is OK to seek help for those kinds of war wounds, and I ask you all to help your buddies understand what you see in them,” he said.

But that was long after O’Brien was hurt. His TBI was not diagnosed for months, until his hip injury landed him back at Fort Campbell in Kentucky. By then, the Army needed help treating TBI cases and was contracting with private rehabilitation centers like Schneider’s at Vanderbilt in Nashville.

Malone and O’Brien were friends helping each other cope.

“They were sent to us together,” Schneider said.

'I have trouble with now'
“I’ll need to get milk and bread and eggs. Milk and bread and eggs. Next thing you know, I drive right by Wal-Mart,” O’Brien said.

“I can vaguely tell you what we talked about at the beginning of this conversation,” Malone said.

Memory trouble is a common sign of TBI. It isn’t like Alzheimer’s disease, where people are so disconnected with reality that they forget things like how a key works or where they live. It isn’t like amnesia, where a chunk of the past is missing.

“I don’t have any problem remembering the past. I have trouble with now,” O’Brien said.

Multiple or complex tasks confound and irritate people with TBI. Therapists challenge them through exercises, like a computer game where they run a hot dog stand and must manage inventory, set prices, do banking and anticipate demand according to the weather.

Other therapy focuses on life skills like following directions while paying attention to something else.

“I counted three trash cans,” O’Brien announced proudly after a scouting mission to find landmarks using a map, tallying cans along the way.

The brain

“I counted five,” said therapist Jenny Owens.

Improving these skills is key to living a normal life and being able to drive.

“Most of them don’t drive. A van brings them down. They were hitting mailboxes, they’d get lost. We draw them maps and they forget when they’re supposed to be here,” Schneider said.

The Army recently gave some soldiers Palm Pilots — handheld computers to help manage their lives.

“It costs them more for us to miss two appointments than to give us one of these,” O’Brien said.

But devices and mental exercises do only so much. Troops must be able to apply information and to reason, but TBI keeps some of them from being aware of their gaps.

“They don’t realize their judgment is impaired,” said Vanderbilt neuropsychologist Elizabeth Fenimore.

Training that helped them in combat situations hurts them now.

“These guys are taught to be alert all the time,” so they sleep poorly, Schneider said.

“Their nervous system becomes acclimated to being constantly on alert — fight or flight,” Fenimore said.

Malone knows it well.

“I worry about every little thing — people breaking into my house, loud booms ... I’m jumpy,” he said.

O’Brien soon will move in with Malone and Malone’s fiancee, Megan.

“Their friendship helped them get better,” she said, “just because they’re not going through it alone.”

Hopes of returning to battle
“I’m going to Afghanistan next year,” said O’Brien, determined to stay in the Army and support his two daughters, who live with his ex-wife in Texas.

“I’m trying,” added Malone. “They’re telling me they don’t think my brain can take it. I think, ’why don’t you let me decide?”’

Doctors do not know whether either will return. But after all they’ve been through, if one does and the other does not, “it’s going to be tough,” Malone said. “It’s going to be tough for whichever one stays back.”

© 2013 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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