A Mystery Of War

The Tampa Tribune/Media General
November 23, 2003

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By Keith Epstein

WASHINGTON – For a guy nearly given up for dead twice, James Sides has had an amazing recovery. Six months ago, he lay trapped underwater in a Black Hawk helicopter. Struck by enemy fire, the chopper had plunged into the Tigris River. He was found many minutes after, still buckled in. Later, at a military hospital in Germany, he seemed hopelessly comatose. Doctors, doubting his chances, nearly yanked him off life support.

These days he has only a few obvious signs of his ordeal – some scars, numbness from damaged nerves and four marks from pins that held a stabilizing titanium rod over his shattered right arm. He takes classes and plays football with his young sons, throwing with his right. “He’s like one of these miracles,” says one of his doctors, Steven G. Scott, chief of rehabilitative medicine at the James A. Haley Veterans’ Hospital in Tampa.

“To be able to play with my kids is everything,” says Sides, his voice quivering. “They could have had no father. They could have had a father who couldn’t play with them. I know there’s a higher power up there taking care of me. Got to be, for me to be doing so well.”

But inside his head, all is not well. The 30-year-old Army sergeant remembers virtually nothing of his time in Iraq. He remembers none of his rescue missions as a busy medic. He doesn’t even remember what he was doing before the May 9 crash – struggling to save an 11-year-old Iraqi boy struck by a land mine. Nor does Sides remember the attack, or nearly drowning. Defense Secretary Donald Rumsfeld visited him at Walter Reed Army Medical Center; he doesn’t remember that either.

In those first days of consciousness, he couldn’t even remember his wife’s name.

He also recalls little of his slow, two-month rehabilitation at the veterans hospital in Tampa, among a handful of centers in the United States where specialists try to remedy the many tricky troubles of the brain and now are grappling with an unexpected surge of U.S. soldiers with head injuries. Soldiers with brain injuries who live throughout the eastern and southern United States are sent to Tampa and to the McGuire VA Medical Center in Richmond, Va. In the West, brain specialists at VA hospitals in Minneapolis and Palo Alto, Calif., are coping with the surge.

Military brain specialists are busy because of the relatively low death toll in Iraq. Advances that are saving American lives in Iraq, it turns out, also are complicating them when the wounded come home. The military has improved at protecting troops from injury, evacuating the wounded quickly and treating them effectively.

Since President Bush declared an end to major combat operations in Iraq on May 1, such efforts have helped to save the lives of all but 286 U.S. personnel. About 1 in 8 American wounded has died, a much lower rate than in Korea and Vietnam, where more than 1 in 4 died, or World War II, where more than 1 in 3 died. Less noticed, however, are the other casualties of this war – at least 2,401 Americans wounded , many with some of the most confounding and life-altering injuries known to medical science.

Although the U.S. military anticipated increased numbers of amputations in Iraq – due to blasts from rocket-propelled grenades and homemade munitions made to maim – nobody predicted the other consequence of this enemy’s improvised style of warfare: A large tide of soldiers with serious brain injuries.

“Who knew? I don’t think any of us expected the nature of warfare as it is now – this is so different from the [1991 Persian] Gulf War,” said Laurie Ryan, assistant director for research at the Defense and Veterans Brain Injury Center at Walter Reed. “We once thought 20 percent of all injuries involved head injuries, but now we suspect it is way, way higher.”

An alarming sign of the emerging trend first surfaced this month, when the brain injury centers identified 105 patients who between June and October had been struck by land mines, rocket-propelled grenades or other blasts. Of the 105, 41 had probable injuries to the brain. Some had concussions. Some had been comatose. Some died. “It’s not always life-threatening, but it can affect the rest of their lives,” Ryan said. “The medical system is really having to gear up for this – so we can make sure patients with brain injuries aren’t overlooked, that they won’t be debilitated, or have far-reaching impacts on their lives beyond amputations or whatever else they’ve sustained.”

Quick Response Can Save

Generally, the wounded are flown to a military hospital in Germany and then to Walter Reed, admitting them lately at a rate of 10 a day. Patients with brain injuries are then airlifted to the specialists at the VA hospitals in Tampa and Richmond who seek to remedy impairments causing behavioral, learning, memory or other problems while rehabilitating soldiers with physical injuries.

Instead of being buried, over the course of weeks and months, they are given new chances at life – although a very different life “In the past, someone like Sergeant Sides would never have made it. But quick response kept him alive and better treatment gave us more to work with – and now he’s on his way to recovery,” said Scott, of the Tampa veterans hospital.

Sides’ memory has improved with treatment and training, but he still can’t even recall the long road trip home from Tampa to Wynne, the small town in Arkansas where he grew up a high school football star and has been welcomed home as a war hero.

“It’s so weird. How do you forget a drive that long?” he asks. “I remember stopping for lunch somewhere. My wife was driving – a little too fast. I remember joking, “Becky, are you trying to kill me again?’ ”

The same upbeat personality that helped his team to a state championship seems intact. But in algebra class, he writes down the rules, only to forget them a moment later. At the store, he buys Dr Pepper – though Rebecca wanted Coke. The other day, Rebecca told him she was going to get the truck fixed. He wondered why, even though she had described problems with the brakes a day earlier – reminding him from the day before that, when he also forgot.

Some memories return, hazily. A guy in his unit sent photos of them wrestling, to relieve war zone stress. This was before the crash. “It’s a little blurry, but I remembered,” he says. “It’s all so weird, like “The Twilight Zone.'”

Brain As Command Center

The human brain – with 1,000 trillion connections and more neurons in its small shell than stars in the Milky Way – is a stunningly complex organ of command and control. It is the Central Command of emotion, the seat of memory and learning, the headquarters that run the muscles, the senses of hearing, smell, taste, touch and sight, and the system ferrying blood and the body’s many chemicals. Thus the slightest disturbance can have all kinds of consequences. A blow or jolt can result in a traumatic injury disrupting normal functions.

When the Black Hawk plunged into the Tigris River, Sides was injured more than was apparent to those who dived into the water from another helicopter to save him. His left leg and right arm were shattered – that was clear. The impact also damaged nerves in his limbs. Only after weeks with physical therapists in Tampa was he able to walk. Walking again is something he remembers. “I went from riding in a wheelchair every day to jogging around the clinic with my occupational therapist,” he says giddily.


But lasting damage lurked within the confines of his brain. The impact of the crash gave him a concussion, and a contusion on the right side. Then, as he was submerged and unable to breathe for more than five minutes, the cellular die-off began. Deprived of oxygen, his brain cells stopped functioning. Many died. Within the brain’s intricate byways of nerves and neurons, he suffered multiple strokes.

His wife reminded him of this the other day – after he said he wanted to return to military service. He felt fine, normal. But he had forgotten the damage. “If all that is wrong, how can I still be, in my eyes, basically OK? Why don’t I have more problems than I’ve got?” he says. “Spots in the brain like that – it can make you a vegetable. But I can walk and think.”

Identifying The Invisible

Among those who have demonstrated seemingly improbable recoveries from damage to the brain and central nervous system is actor Christopher Reeve, paralyzed from the neck down in a horse riding accident in 1995. This month, the quadriplegic star of “Superman” is breathing without a ventilator for hours at a time – and predicting some day he will walk. “

As Christopher Reeve shows, the central nervous system can recover from these traumatic events. We gear our rehabilitation to that new mode of thinking,” Scott said.

The military hospitals actively try to identify soldiers with brain injuries – in contrast to traditional practices, which neglected the brain for attention to other injuries. The difficulty, military doctors say, is that brain injuries are not always readily apparent.

Even before the war, Gretchen C. Stephens, the VA’s Richmond-based national traumatic brain injury coordinator, regularly cautioned nurses to be on the lookout for signs of a brain damage, often referred to as a “hidden disability.” “Persons sustaining a brain injury are often described as the “walking wounded ,’ ” she said. “Many of their challenges are invisible to the average person. While someone with a brain injury may “look normal,’ this individual may have difficulty with routine daily tasks due to damage to the brain in areas that control memory, concentration, communication and emotions.”

Many veterans have sought medical attention months or years after the initial injury. These days, doctors, nurses and therapists are on the lookout for telltale signs of brain injury among the wounded – memory loss, slowness in processing information, attention deficits, altered vision, loss of smell or taste, changes in sleep, difficulty with balance, agitation, impulsive behavior, and a host of other symptoms.

Each list of fresh casualties in Iraq is combed by brain injury specialists for signs of those who have fallen, been in vehicle accidents, been struck by explosive weapons or been in a helicopter crash.

Working Hard To Help

In Sides’ case, the experts in Tampa designed a rehabilitation program for him, which continues. Specialists still keep tabs on changes in his brain through MRI scans. “He’s made great improvements, but we’re still trying to train him, memory-wise,” Scott said. “The sad part is these problems can persist. “We have some people with no memories except for the distant past. We have some people who are very impulsive or depressed. They’re young, and they have families, and so it’s awfully hard on everybody. These are about as complex a rehab as you can have.”

Some patients need modifications at home, such as a ramp or a wider doorway. Others need intensive therapy and training sessions to improve retaining what they learn. Scott tells patients: “You fought for our freedom, so now we’re here to give you your freedom back.”

At home these days, Sides plays memory games with sons 6-year-old James Jr. and 7-year-old Devin. They line up playing cards, face down, trying to find matches. They play “Simon Says.” They play anything Sides can think of that helps him improve his memory. “The 7-year-old beats me at memory games, to be honest,” he says. “But in Tampa they said anything I can do for my memory would help it a little.”

Giving up just isn’t on his agenda. He sounds as if he is still preparing for a big high school game. “My goal is to be 110 percent. I don’t want to be back to as good as I was. I want to be better than I was. I want to go back in the military. Not that I’d jump in a helicopter, but to contribute and to get a degree to work as a nurse.”
His doctors, for all their knowledge, are unsure whether that can happen. “He’s really improving, but we don’t know how far he’ll go,” Scott says. “Only the big guy in the sky knows that.”

“The way I look at it,” Sides says, “anything I can’t do, maybe I wasn’t supposed to do. Things happen for a reason, even these things. The best explanation I have for it now is, I’m home with my boys. To me, that alone is enough of a reason for this to have happened. I was thousands of miles away and might not have come home. This is great! How can I complain?”