Treating war's 'silent injury'
They may have no visible wounds, but Marines with brain trauma face many
By Tony Perry
Times Staff Writer
April 11, 2007
ENCINITAS, Calif. — At a community hospital here, doctors and therapists are
working to help Marines overcome what is often called the signature injury
of the Iraq war: brain trauma with no visible wounds.
"It's the silent injury," said Jessica Martinez, an occupational therapist
at Scripps Memorial Hospital Encinitas. "With every blast they suffer, their
brain is rattling like a yolk in an egg."
Marine Lance Cpl. Brian Vargas was a high school football player. Now, even
though he looks fit, he cannot toss the football with his buddies, let alone
be part of pickup games with other off-duty Marines.
"I can't catch anything," he said. "I can't remember any plays."
Vargas, 20, was subjected to innumerable mortar and roadside bomb blasts
while patrolling the insurgent stronghold of Hit in the Euphrates River
Valley. In mid-January he was shot in the hand and cheek by a sniper and
airlifted to Germany and then the United States for treatment.
He has the classic signs of post-concussive injury.
"My thinking has gone down," he said. "I can't remember what I did this
morning. I have trouble putting memory and speaking together. I'm trying to
learn to speak as clearly as possible."
Lance Cpl. Keene Sherburne, 20, who was injured when a bomb exploded under
his Humvee in Fallouja, is frustrated at the slow pace of his recovery.
"I can't read," he said. "I used to love it, but now I hate it. I pick up a
snowboard magazine, and I get so mad because I don't understand it."
For most of the Marines, who come here from nearby Camp Pendleton, the
regimen is six hours a day, three days a week. Physical therapists work with
them to restore their balance, hand-eye coordination and stamina. Counselors
work on behavioral changes and anger management. Occupational and speech
therapists work on language skills and on restoring their memories.
In one exercise, Marines listen to words being defined and then are asked to
repeat the definitions. Sometimes their wartime experiences intrude.
Asked to define "cherry," Vargas could not remember, but he recalled
something else: "That was the name of the street I was walking over when I
Experts say studies of civilians with mild to moderate brain injuries
suggest that they can recover. But it remains unknown whether military
personnel, whose injuries are coupled with the experiences of war, have
For a decade, the Encinitas hospital has had a contract with Camp Pendleton
to provide care for active-duty personnel and their family members. As the
numbers of brain-injured Marines and sailors mounted, the contract was
expanded last year to include those kinds of injuries.
The more severe cases in which the skull has been damaged are treated at
acute-care hospitals, including the Department of Veterans Affairs center in
Palo Alto. Often, brain injuries without outward wounds go undiagnosed.
Symptoms can be slow to appear. Brain injuries such as those suffered by
Vargas and Sherburne commonly do not show up on MRIs or CT scans.
There is also the complicating factor of Marine Corps culture.
"Marines are taught to be self-reliant, to not complain, to 'suck it up and
do your job,' " said Dr. Michael Lobatz, director of the rehabilitation
center at Scripps-Encinitas and a clinical assistant professor at the UC San
Diego medical school. "As a result, Marines are often delayed in getting
recognition for their symptoms."
At Camp Pendleton, Marines are examined for possible concussion injuries
when they return from Iraq and again 90 days later. Those showing signs of
injury are referred for further examination at the base hospital's
Navy doctors and corpsmen, as part of their pre-deployment training, now
receive additional instruction in how to spot and treat brain injuries.
A study by the Defense and Veterans Brain Injury Center at Walter Reed Army
Medical Center in Washington, D.C., suggests that "closed-brain" injuries —
those without visible wounds — outnumber penetrating brain injuries by 7 to
1. Navy Capt. Edward Hessel, the top doctor with the 1st
Marine Division, said he thinks the number may be far greater.
Maj. Gen. John M. Paxton Jr., commanding general of the 1st Marine Division,
said Marine leaders became concerned when they noticed that some Marines
returning from Iraq were "struggling emotionally."
"It's like football or boxing injuries. You never know the cumulative
effect," he said.
The surgeon general of the Army ordered a report done on traumatic brain
injuries and possible treatment plans. The report is due May 1. Two
battalions from Camp Pendleton have been selected for another study on brain
injury assessment and treatment in Iraq.
One preliminary study at Walter Reed suggests that patients with mild
traumatic brain injury are at greater risk of developing post-traumatic
stress disorder than patients who have suffered even greater brain injuries
through direct wounds.
Many of the symptoms of mild brain trauma and post-traumatic stress disorder
overlap: anxiety, memory loss, depression, loss of concentration.
Physical exercise is an integral part of the regimen. But brain injuries
often impair balance. There can be a disconnect between the brain and heart,
so the latter will not pump enough blood to allow for exertion.
"It's so hard for them to back off," said physical therapist Rebecca Askew.
"They're used to being able to run, jump and climb, but now the only thing
they can do is walk."
So far, the hospital has treated 31 Marines with therapy and visits with the
neurologists. Two-thirds have been declared fit to return to active duty,
the goal of the program, officials said.
Sherburne is in the process of receiving a medical discharge and still
dreams of becoming a professional snowboarder. Vargas would like to remain
on active duty, at least through the final two years of his enlistment.
"I want to stay in," Vargas said. "This is my job. I'd like to become an
instructor, maybe teach my guys how to survive in Iraq."
Copyright 2007 Los Angeles Times