TBI: vets, VA face new war's hallmark injury.

Army Specialist Claudia Carreon thumbs through a photo album. It is full of smiling faces--cousins, aunts and uncles, friends; her mother, her husband, her daughter. The photos reassure her. They make her feel loved. And as she studies the faces, she tries to remember.

Handwritten on each photo are captions with names. And there are notes. Claudia's always writing notes. She has a special iPAQ handheld personal computer, and she keeps a thorough diary and date book. They call it her "prosthetic brain." It bridges the gaps in short--and long--term memory caused by her traumatic brain injury, or TBI.

"I don't remember the events. That's why I take so many notes," she says. "It's discouraging to look at pictures of myself and not even know why I'm smiling." When were you hurt? How did it happen? When did you get married? Claudia goes to her iPAQ to find the answers.

On June 10, 2003, Spec. Carreon, a member of the Arizona National Guard serving in Iraq, was involved in a head-on automobile collision in Baghdad. An Iraqi citizen died at the scene. Following initial treatment for injuries from the accident, Claudia was returned to duty.

Then less than a month later, she was demoted to private first class for failure to follow an order. People in her unit didn't realize she was hurt; she couldn't remember things.

Eventually, the injury was diagnosed and Claudia was medically evacuated from Iraq. She was transferred to the Army Reserve and promoted. After getting her rank back, she was sent to the Department of Veterans Affairs Palo Alto Polytrauma Center to restore everything else.

"My long-term memory is bad. But my short-term memory is getting better," Claudia says. "From last week to today I can see improvement. My awareness is much better."

She speaks with some confidence-confidence she will need as she faces an uncertain future.

50 first dates

Like the leading lady in the movie 50 First Dates, Claudia must relearn the most intimate details of her past.

It is a daily struggle to rebuild her relationship with her husband from scratch. She and Richard, an active duty Coast Guardsman, married in late January of 2003--before the accident.

"I only know I'm married because I have a wedding band," she says. "He tries to pull memories out. It's very difficult. We end up being mad at each other."

She doesn't know her two-year-old daughter Sandra Rene. "I can't remember being pregnant or giving birth," Claudia says.

She's apprehensive about what the future holds. She says that the prospect of going back to the regular Army before being discharged is "terrifying." A proud soldier, she doesn't want to get in trouble for making mistakes because of her brain injury.

That there are no visible indications of disability beyond knee braces makes things more difficult for Claudia. If people don't see a physical wound, she notes, "they assume you are doing great."

She's also nervous about reuniting with her husband because of the strain her injury has placed on their relationship.

Claudia's story is unique. But where she lives, and trains, and rehabilitates, uncommon stories are common.

Fighting through fire

Retired Staff Sgt. Faoa Apineru says his Marines called him AP because his name was too hard to pronounce. The muscular native of American Samoa sits down at a hospital table and begins to draw. He says it helps him to "put things in the right order."

In February 2005, he was a communications chief for the Marines guarding the Iraqi border with Syria. That's when one of his troops, Cpl. Christopher Winchester, told him it was time to start taking it easy.

"'Too many patrols,' he told me. So he took my gear. Can you believe that? A lance corporal took my gear?" AP asks, flashing a photo of the two together. "Other people looked at me and they thought it was crazy that I was taking that. But I knew he was looking out for me. I knew he cared about me."

AP doesn't remember getting hurt. But, he's pieced things together through his Marines' accounts. He plugs a thumb drive into a computer and clicks around until an unusual sound fills the air. Foreign voices sing as the computer displays masked gun-men in Arab headscarves.

A few clicks later and the screen shows a shaky roadside view of the Iraqi desert.

"My guys sent this to me. It's an al Qaeda recruiting video. Here it comes," AP says with little fanfare. In a moment, a military vehicle crosses the screen from the right. A few seconds later, a Humvee follows it. The Humvee is barely in full view when an improvised explosive device, or IED, is detonated. Flames completely engulf the vehicle as it drives into an exploding wall of fire.

"That was me," AP says.

It's difficult to believe that anyone could survive such a horrific attack, but every Marine in the Humvee lived. "I stood up to check my glasses. All they saw was blood all over. I don't know how long I was up. They told me I got out my M-16 and tried to shoot." AP and his driver, a lance corporal, took the brunt of the blast.

After the explosion, with everyone clear of the flames, AP slumped over and his Corpsman came to his aid. There was blood soaking the shoulder of his uniform. His Marines frantically ripped away his clothing in search of shrapnel, but found nothing. "Eventually, they realized the blood was coming from my face, from my head, my nose and mouth--from in there."

For AP, the most traumatic event surrounding his injury was the day he awoke.

"I thought I was dead. And then, I thought I was caught by the Iraqis. Nothing told me I was in America. Everything was blurry. I couldn't speak. I didn't know how to speak. The smell was one of the worst things. And the nurse wasn't white. Eventually a doctor came in. And he spoke to me with a Mexican accent. He told me I was going to be alright and I felt a little bit better," says AP.

His mother and sister were at his side when he came to, but couldn't provide any comfort. He couldn't recognize either of them. There was shrapnel lodged in the back of his brain, his energy was gone, and he'd torn the anterior cruciate ligament in his knee.

"I was afraid to sleep because I hated the feeling of waking up. I keep flags and perfume everywhere in my room because they make me feel better, like I'm home," he says.

Always a Marine, AP said the thought of recovery has motivated him. The former marathon runner doubles his recommended physical rehabilitation training regimen. He battles disturbing thoughts caused by post-traumatic stress, and has struggled with depression.

He feels guilty and helpless about not being able to support his fellow Marines who continue to serve. On July 14, four months after AP's injury, Cpl. Winchester was killed in battle. The news devastated the staff sergeant who looked at his junior troop as a caring friend who foresaw, and tried to prevent, his devastating injury.

Apineru regularly gets headaches, which typically start where the shrapnel is lodged in his brain. He says they are so severe they feel like "a Ka-Bar (knife) stabbing and ripping." He blanks out occasionally. And while he's recovered significantly, he says the loss of personal confidence is devastating.

He'd planned on marrying his girlfriend. But she left him when she learned the extent of his injuries. He's learning to adjust his plans around the disabilities which may likely affect every aspect of the rest of his life.

"Sometimes I wished I was dead so I wouldn't have to worry about the (medical) boards, memory therapy, anxiety, headaches, pain," AP says.

With time, though, his confidence has improved. His corpsman and fellow Marines keep in touch and several have come to visit. He's reestablishing relationships with his family in American Samoa, but he isn't sure where he wants to live when the majority of his rehabilitation is completed. "I haven't been back home in 10 years. But I'd like to go there on vacation. Maybe I can start remembering things."

"I try to look on the bright side. I mean, I'm starting over. I have a lot of people supporting me. I'm a Marine and it's hard to ask for help. But when I'm here, I know I people are around who will help me," says AP.

With drastically improved body armor, battlefield medicine techniques and faster evacuations, an increasing number of men and women, like AP, are surviving severe injuries that would have meant certain death in previous conflicts.

The 'hallmark' injury

It has been said that traumatic brain injuries--caused by IEDS, mortars, vehicle accidents, grenades, bullets, mines, falls and more--may be the hallmark injury faced by veterans aofIraq and Afghanistan.

How the victims of TBI are treated, and the rate and extent of their recovery at polytrauma centers and beyond may be a hallmark response in the VA's long history of serving veterans. At four regional centers in Minneapolis, Tampa, Richmond and Palo Alto, veterans and active duty military members receive the best in rehabilitation and care.

On any given Tuesday morning, a massive gathering of rehabilitation nurses, physical therapists, occupational therapists, speech pathologists, recreation therapists, neurophysiologists, counseling psychologists, case managers, social workers, dieticians, researchers and chaplains gather under fluorescent lights in a room at the Palo Alto Polytrauma Center. A patient's name comes up and the case discussed around the room.

A speech pathologist may talk about the progress a patient has been making since he or she attended a hockey game in San Jose the week before. Then there is a discussion. If there is a way to use an advance in one area of treatment or rehabilitation to help the veteran in other areas, the entire team works together to ensure the most productive and advanced techniques are used.

Every aspect of each patient's treatment is up for discussion, and every member of the team works together to coordinate and maximize their efforts.

Many of the veterans arrive at the facility shortly after being medically evacuated from Iraq and stabilized in Landstuhl, Germany, or Walter Reed Army Medical Center. They may have milder injuries, but many are barely responding to normal stimuli when they show up. They may have open wounds, facial injuries, burns, broken or missing limbs, spinal chord injuries-each patient shows up with a particular combination of physical and psychological trauma.

The doctors have to deal with their injuries and their pain. They have to balance medications and narcotics to allow patients to comfortably and efficiently heal and recover as much as possible.

"We're dealing with many different issues at the same time. We use our specialties and work together as a team," said Dr. Elaine Date, Medical Director of the Palo Alto center. With more than 20 years of experience working with brain injury victims in the VA, Date said there have been remarkable advances in the treatment and rehabilitation. "Our goal is to get each patient to maximize their physical and cognitive functions and to let them move on with their lives," she says.

Taking on trauma

The current war's traumatic brain injury victims have some of the most complex physiological and psychological issues in the history of battlefield medicine. When hit by an explosion, like AP's IED, the force of the blast instantly overcomes the victim. The same explosion that is powerful enough to upend a 25-ton armored vehicle can shake the brain and cause permanent damage.

Even after the trauma from the explosion, secondary injuries to the brain and body can be caused by shrapnel and other damaging events.

TBIs are also caused by rocket propelled grenades, bullets piercing the skull and directly damaging the brain and a variety of other battlefield hazards.

When soldiers go down with a brain injury in the field, and their survival is at stake, modern corpsmen or medics are trained to perform craniotomies to allow the brain to swell and other advanced life-saving procedures.

The quality treatment patients receive immediately following the injury, the speed at which they can be removed from the battlefield to be stabilized and the care that follows have dramatically improved the survival rates and recovery among the injured.

The fact that many of the injured are relatively young means their brains have more plasticity and will likely be able to reorganize neural pathways based on new experiences and rehabilitation.

TBI has been called "the secret epidemic" because it's unknown how many people live with brain injuries. Milder injuries, even those that might significantly impact someone's health and life, may go undiagnosed.

A study compiled by the Defense and Veterans Brain Injury Center at Walter Reed Army Medical Center found that more than half the servicemembers with serious injuries to the head, face or neck, suffered moderate or severe brain trauma.

As a result of TBI and other service-connected conditions that are becoming increasingly common, all Operation Enduring Freedom and Iraqi Freedom veterans who return with certain symptoms receive a comprehensive screening. It's possible still that many have already gone undiagnosed and that symptoms for others may not surface until later in life.

For VA doctors, the TBI statistics coming from modern war veterans raise sad questions from the past. How many veterans of Vietnam and other wars may have returned with minor or severe brain injuries that went undiagnosed?

The influx of young men and women with brain trauma has increased research into the injury. And VA specialists see encouraging results while testing the effects of some common medications. Doctors from the Palo Alto center routinely share their knowledge with colleagues and students at nearby Stanford University.

When it comes to these veterans' overall care, a July assessment from the VA Inspector General found room for improvement. According the VA's report, better coordination of care was needed to allow veterans to make a smoother transition between Defense Department and VA care.

The report also called for additional help for the family members and other long-term caregivers and improved case management. While families are bending over backward to support their loved ones, the VA recognizes they need and deserve help.

Already, a Veterans Health Administration directive is defining roles for staff at VA facilities to "ensure a seamless transition of care."

Further, in response to the success of the regional centers and growing demand, the VA is expanding care to other facilities, creating Level 2 Polytrauma Centers throughout the country so veterans can get follow-up care and rehabilitation closer to home. Plans for Level 3 facilities, which will expand care to even more locations, are underway.

BaCk to basics

The first step toward identifying TBI comes from an analysis of the injured member's post-traumatic amnesia. Through a series of tests, VA specialists study the extent of brain damage and may estimate the level of recovery a patient might gain over a specific period of time.

"We rely on our experiences, but our patients' progress never ceases to surprise us, especially in terms of cognitive recovery," says Dr. Date. "Some of these people literally come back to life in front of us. Some of them barely come back at all. We try not to predict miracles, but we welcome them when they occur."

Families are welcome at the Palo Alto center and often stay at the local Fisher House, a short walk from the facility. Through participation, the center provides guidance and resources that will help spouses and parents learn to care for the injured veterans.

For a facility known for housing some of the most severely disabled veterans in the country, staff members, the patients and their families are remarkably upbeat.

"He came back (from Iraq) alive, there's no point in looking back," said Linda Cagle, mother of retired Army Staff Sgt. Eric Cagle, 26. "We can't do the 'what if' thing. That just drives you crazy."

TBI has also been called the "invisible wound," because serious injury can be sustained without visible indicators. Eric Cagle is not one of those people. On Oct. 14, 2004, an IED blasted his Humvee. Between his body armor and helmet, shrapnel entered his skull under his left eye and lodged in his brain. It took three emergency brain surgeries to keep him alive. Doctors tied off his carotid artery, causing a stroke, but saving his life.

When he woke up days later at Walter Reed, Cagle thought he was still in Iraq. He couldn't see and was partially paralyzed. In surgery, the entire right temporal lobe and part of the frontal lobe of his brain were removed. He suffers chronic fatigue and narcolepsy. He has no real sense of time, five minutes; he says, can feel like five hours. He's blind in one eye and suffers from slight dementia.

Cagle's wife of three years divorced him last year. And his mother, Linda, a computer programmer in Tucson, Ariz., and father, Jim, a Michigan emergency room doctor, are challenged to maintain their careers and make the long trek to Palo Alto.

Still, no one in the Cagle camp complains about Eric's disabilities. They are too focused on his recovery. "There're so many folks around here whose situation is so much worse. (Eric's) intelligence has stayed intact. He was a bright person before and is still a bright person," Linda Cagle says. "There is a sense around here that things are only going to get better."

Eric looks forward to challenges and improves dally. It's a slow and arduous process. Every day is full--physical training, therapy, counseling, more therapy. In his free time, he listens to books on tape. He's retraining his brain and overcoming paralysis. His cognitive abilities constantly improve, so do his communication skills and nearly every other aspect of his rehabilitation.

When Eric is finished at the center, he plans to go to college to study forensic science. He wants to work in a crime lab.

"The best thing you can tell me is that I can't do something. One time someone told me that I couldn't walk," Eric says. Today, he can walk short distances with a cane. "My goal, one day" he says, "is to get out of this chair and walk right out of this hospital. And I'm going to do it."