Back at Taji again, Zacchea was having problems. His headaches had intensified. He couldn’t eat. He couldn’t sleep. He was constantly irritable. He still was thinking that everything was related to stress—and with good reason. His men had become targets of insurgents trying to frighten Iraqi troops into deserting. Six of them had been abducted and beheaded. Five more were kidnapped and tortured. Making matters worse, he’d been told that the 288 men in his battalion were going to have to take on sole responsibility for defending Taji in place of the brigade of more than 2,000 men that was being sent up to join the fight in Mosul. Zacchea was worried that they were now far too shorthanded to protect the base from insurgent attacks.
In January 2005, he learned of a plot to assassinate him. He decided to take a wait-and-see approach and eventually broke up the conspiracy, but all of that just compounded the tension. Zacchea was sure that the stress from the plot and the constant attacks on his men were taking a toll on his own health. Finally, he went in to the stress clinic at the neighboring Camp Cooke and met with a psychiatrist who asked him to complete a questionnaire designed to ferret out cases of post-traumatic stress disorder and traumatic brain injury. Zacchea checked “yes” to almost every question, including the ones asking if he’d been involved in a blast or vehicular accident. He indicated that he’d lost consciousness during the blast and had seen stars during the wreck. He noted that he had been experiencing headaches, sleep problems, and a constant sense of irritability since then. When the psychiatrist rendered his opinion, it confirmed Zacchea’s suspicions: post-traumatic stress disorder, or PTSD. The psychiatrist thought Zacchea ought to rest. But military commanders were unwilling to let him take leave—or even take any time off. Iraqi elections were coming up soon and they wanted security to be tight. So Zacchea continued to go out on combat missions for the next two months.
When he was finally sent back to the United States, his first stop was at Quantico, Virginia, where marines are out-processed. There, physicians noted that he’d been decorated for bravery and recommended for the Purple Heart. They read the descriptions of the vehicle crash and the RPG explosion. They saw the diagnosis of PTSD. When Zacchea told them about the headaches, the sleep problems, and the anxiety, they recommended that he check everything out with his family doctor when he got home.
Zacchea had always figured that his symptoms would resolve once he got away from the battlefield. But when he arrived home in Hicksville, Long Island, his symptoms only intensified. His migraines were lasting longer. He’d spend entire days lying in a darkened room, vainly trying to ease the throbbing in his skull with regular doses of Excedrin. When his head didn’t hurt, he was consumed with anxiety and anger, though he never could pinpoint what was triggering either emotion. He would sometimes become paranoid, once barricading himself in his mother’s basement, and sometimes fly into a rage. His memory was starting to fail. He often couldn’t remember his phone number and would get lost on short trips away from home. He would set out for the grocery store but would forget what he needed to buy by the time he got there. His fiancée was worried about him. She’d noticed that along with his other symptoms, Zacchea now seemed to have problems talking. Once a fluid conversationalist, he was talking slowly and his speech patterns had become choppy. He was having trouble finding words and he had developed a stutter. She didn’t know what was wrong, but since he’d been diagnosed with PTSD, she urged him to see a psychologist.
All the while, Zacchea was making monthly visits to the Veterans Affairs Medical Center in Northport, Long Island, to get help with the pain in the shoulder that had been fractured in Iraq. He told doctors there about the headaches, the memory problems, and the irritability. They told him his symptoms were a result of his PTSD and never referred him to a neurologist.
In 2005 he returned to his job as a financial analyst with the Wall Street firm he’d worked at before being sent to Iraq. It didn’t take long for his uneven moods to convince his bosses to restrict his contact with clients, so Zacchea found himself concentrating on data collection and market analysis. But even then things didn’t go smoothly. He was having trouble with work that had come easily before. His brain seemed to have lost the ability to organize and analyze. He couldn’t stay focused. Coworkers told him that since he’d come back from Iraq, he’d been “out in left field.” By this time, he knew there was something seriously wrong with him. He was beginning to realize that even if he did have PTSD, that diagnosis couldn’t explain all the bizarre symptoms he had been experiencing. He wondered if something had gone wrong with his brain, though he still hadn’t connected his symptoms with the jolts he’d experienced in Iraq. He made his case to doctors at the VA, but they refused to refer him to a neurologist.
As time went on, work became even more of a struggle. He was having trouble with fairly simple math, with numbers in general. Then in 2008 he got a call from ABC News. The producer on the phone told him that Bob Woodruff wanted to interview him for a piece that would appear on the evening news exploring the stigma associated with PTSD. One of the veterans’ support groups had recommended that ABC contact Zacchea for perspective on the syndrome. During the interview in Central Park, Zacchea talked about the stigma of PTSD. Within a week of the broadcast, doctors at the VA wrote Zacchea a referral to a neurologist from the Yale School of Medicine who was doing some contract work for the military.
Dr. James Hill listened to Zacchea’s symptoms and examined him. His diagnosis: Zacchea did indeed have a traumatic brain injury, as well as PTSD. “You should have been in here years ago,” Hill told the marine. The neurologist then explained what happened after a TBI. “Your brain is like a computer,” he said. “What happens in a TBI is that the operating system gets a glitch in it. It’s like you dropped your computer and then it didn’t work right anymore.” Hill sent Zacchea off for neuropsychological testing to confirm the diagnosis and to pinpoint the marine’s deficits. The tests showed that Zacchea was actually getting worse with time.
Zacchea went to his Wall Street bosses with his new diagnosis and asked for some time to try to get rehab. He was also hoping for some accommodations that would make his job easier. But they weren’t interested in that approach. In fact, they started to complain about all the medical appointments and the time he was spending on the phone with his doctors. They told him that he could get rehab while out on short-term disability and that he shouldn’t expect his old job back when that was done.
The treatment he got from the military wasn’t much better. He had been a career officer, having enrolled in the ROTC before starting college at Notre Dame. He had planned to stay with the Marine Corps until retirement just as his father and grandfather had done. But the Marines weren’t interested in finding a place for a man with a brain injury and PTSD, even in the reserves. Once he accepted the idea that they weren’t going to find a position for him, Zacchea tried to get the Navy to retire him, but that turned out to be just as complicated as everything else in his life now. Navy officials told him that despite all the doctors’ reports saying that he wasn’t able to continue as a marine, he ought to be able to return to work—based on his past performance. It was a classic catch-22: he was told he couldn’t retire because he was healthy enough to get a job with the Navy, but there was no job there for him.
While he appealed the decision, Zacchea found rehab with a private neurological facility. Doctors prescribed medications to help with his migraines and insomnia. Therapists worked to improve his memory and make his speech more fluid. They helped him develop strategies to compensate for his problems with organization and planning.
Realizing he was never going back to the Marines, Zacchea enrolled in a graduate school program at the University of Connecticut focusing on business and policy. He planned to help design a UConn program for disabled vets. After his struggles with his job and the military, Zacchea considers his university experience “the one bright spot.” Right from the start, the school was willing to accommodate his disabilities. Pro
fessors gave him extra time for tests and were understanding when he forgot assignments. They gave him time to make up work when a migraine broke through and put his life on hold.
Even with those accommodations, Zacchea is sure he wouldn’t be where he is today without his wife. “She’s hung in there against all odds,” he says. “This is not what she signed up for. It can be really difficult at times. I forget a lot of things. Sometimes I forget to take a shower or to brush my teeth. Sometimes I forget to eat. Sometimes I eat twice because I forget that I already ate. She reminds me and sort of keeps me going. She reminds me about deadlines at school. I’d be floundering without her.”
Zacchea’s long-term plan is to work with disabled vets trying to make their way back into work and society. Energized to find a new path in life, he hopes that he’ll be able to put his degree to use helping veterans like him who have slipped through the cracks.
• • •
As the wars in Iraq and Afghanistan ground on, reports began to crop up in newspapers and magazines describing the plight of soldiers and marines who, like Zacchea, had come back with undiagnosed brain injuries. They were struggling to adjust to life at home while having to deal with strange symptoms that no one around them could explain. Traumatic brain injury was still under the radar as far as most Americans were concerned. But some experts were beginning to warn that the issue was going to explode as the numbers of veterans from the wars in Iraq and Afghanistan grew and grew. Doctors who treated the returning vets dubbed TBI “the signature wound of the war,” because they were seeing such a high percentage with lasting brain damage. At Walter Reed Army Medical Center in Washington, D.C., where many of the most severely injured soldiers were being treated upon returning to the United States, everyone got checked for TBI. Doctors there found that about 60 percent of the soldiers had suffered TBI, with more than half of those brain injuries diagnosed as moderate or severe. Wayne Gordon and other TBI experts were convinced that the brain injuries spotted by doctors at military hospitals were just the tip of the iceberg. Without routine screening, Gordon said, there was no way to prevent brain-injured soldiers and marines from slipping through the cracks.
It’s not that TBIs were unheard-of in previous conflicts, but rather that the proportion of military personnel returning from Iraq and Afghanistan with significant injuries to their brains was far greater. The rise in the incidence of traumatic brain injuries resulted partly from the widespread use by insurgents of improvised explosive devices, or IEDs. Ironically, it also resulted from innovations in protective gear and emergency medicine. Soldiers who might have died in earlier conflicts were surviving this one because high-tech helmets and body armor protected the head and torso from penetrating wounds. Advances in first aid and quicker trips to sophisticated medical centers were saving soldiers who might have died on the battlefield in previous wars. But many of those who escaped death because of these advances were surviving with badly wounded brains.
By 2006, experts at the Defense and Veterans Brain Injury Center were beginning to appreciate the scope of the problem. “TBI looms large in terms of chronic consequences,” said Dr. Warren Lux, a neurologist then serving as the center’s acting director. “Brain injuries, like amputations, are for life.”
And while the Department of Defense was counting the numbers of dead and wounded, it wasn’t keeping track of mild-to-moderate brain injuries, especially those that occurred without life-threatening wounds to the body. The military still hadn’t recognized that significant brain damage could result without any external signs. Nobody was systematically checking soldiers and marines for brain damage after blasts. The troops themselves weren’t aware that their brains could be harmed by these invisible wounds. Many chose to stick by the sides of their comrades rather than get checked out after a blast. “A lot of guys don’t want to leave their buddies after they’ve been injured,” Lux explained. “They try to tough it out.”
The issue came front and center when Bob Woodruff, the ABC News anchorman who had sustained a traumatic brain injury while covering the war in Iraq, put together a prime-time special on TBI that was broadcast by the network in February 2007. By taking Americans through his painful road to recovery, Woodruff put a face on the invisible injury. After telling his own story, Woodruff broadened his report to look at what was happening to soldiers and marines who had suffered wounds like his. He brought the military’s polytrauma wards into the nation’s living rooms and showed Americans the suffering of soldiers who were having an even harder time recuperating than he had. He exposed problems with the Department of Veterans Affairs’ treatment of brain-injured soldiers through the heart-wrenching story of Sergeant Michael Boothby, who, after improving under the care of doctors at the Navy’s premier hospital in Bethesda, had begun to lose ground when his case was transferred to the VA hospital near his hometown of Comfort, Texas. For many soldiers and marines, there was no continuity of care once they left polytrauma wards, Woodruff reported. He then took the military to task for letting brain-injured soldiers slip through the cracks, making his case with the story of a soldier who had suffered through a year and a half before he was able to convince the VA that his disparate and debilitating symptoms were the result of a TBI.
Even with all the media attention, though, there was a segment of the military pushing back. Some medical officers insisted that the majority of brain injuries were mild, transient phenomena and that screening for them might cause more problems than it would solve. In a study published in The New England Journal of Medicine in January 2008, Army researchers went so far as to suggest that if doctors diagnosed mild traumatic brain injuries in soldiers and marines, it would cause the service members anxiety and slow their recovery. “If you tell a soldier he’s got a mild traumatic brain injury, he’ll think, ‘Maybe I’m brain-damaged,’ ” said the study’s lead author, Colonel Charles Hoge, a psychiatrist and the director of the division of psychiatry and neuroscience at the Walter Reed Army Institute of Research. “They don’t realize how remarkably resilient the brain is. Then they read in the papers that exposure to a blast leads to brain damage, and that elevates their alarm further.”
For the journal study, Hoge surveyed 2,525 soldiers three to four months after their return from a yearlong deployment in Iraq. The soldiers were asked about a host of symptoms, including various types of pain, sleep issues, irritability, and problems with memory and concentration. The soldiers were also asked whether they’d been injured during deployment by a blast or explosion, a bullet, a fragment or shrapnel, a fall, a vehicle accident, or other means, and whether the injury involved the head. Soldiers were presumed to have had a mild traumatic brain injury, or mTBI, if they checked one of the following: lost consciousness, became dazed or confused, saw stars, had some sort of amnesia. Hoge and his colleagues also asked the soldiers to complete questionnaires designed to ferret out depression and PTSD. When the Army researchers analyzed the responses, they determined that almost 15 percent of the soldiers had suffered mTBIs and that these service members were more likely than those with other injuries to have been hurt in a blast. Further, the researchers concluded that soldiers with mTBIs were more likely than others to be suffering from concentration difficulties, memory problems, ringing in the ears, and regular bouts of irritability. Many of the soldiers who met the criteria for mTBI also appeared to have PTSD. Then the researchers took a leap in logic that many concussion and brain injury experts criticized: Hoge and his colleagues insisted that the vast majority of symptoms suffered by these soldiers could be explained by PTSD, rather than by a TBI. Because of this, Hoge concluded, it would be better to just focus on treating the PTSD.
Hoge went on to suggest that the best course would be to tell brain-injured soldiers that they had sustained a “concussion” rather than a “mild traumatic brain injury.” That’s because soldiers would associate concussion with an injury they knew occurred in sports, an injury that had the reputation for being mild and transient. The soldiers would ex
pect to get better quicker than they would if they thought they had a brain injury, Hoge said, and they actually would get better quicker.
Not long after Hoge’s paper appeared, a 499-page report was published that examined the toll that TBI and PTSD might be taking on service members coming back from the wars. The report, which was compiled by the RAND Corporation, estimated that by 2008 as many as 320,000 soldiers and marines had suffered mTBIs, while 300,000 had ended up with major depression or PTSD. Almost 50 percent of the soldiers with depression or PTSD had not sought treatment, and almost 60 percent of those with a probable TBI had not been evaluated by a physician. The report warned of “long-term, cascading consequences” if service members with these health issues didn’t receive treatment. Those consequences could include drug abuse, unemployment, increased marital problems, and suicide. The RAND report figures were a far cry from the numbers being posted by the Department of Defense: 43,779 TBIs through the end of 2007.
When the RAND report was published, Hoge attacked it in the pages of The New England Journal of Medicine. He insisted that the numbers cited in the report vastly overestimated the number of service members with head injuries. Further, he argued, the report’s suggestion that soldiers be screened for mTBI would have negative consequences, leading them to think their brains were permanently injured, which would lead to slower recoveries. Beyond this, soldiers might be diagnosed with a brain injury when they didn’t have one and then receive inappropriate medications.
The Concussion Crisis Page 15
