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06-12-05, 07:15 AM
Shattered survivors from Iraq
With bombs the insurgent weapon of choice, many U.S. soldiers who survive the explosions must learn to live with missing limbs or damaged brains. Walter Reed hospital is a microcosm of the challenge.

By Jonathan Bor
Sun Staff

June 12, 2005

WASHINGTON - In his last memory of Iraq, he was riding in a Humvee on the main highway south of Baghdad. Ten days later, Army Sgt. Joey Bozik opened his eyes in a hospital to find that his right arm was missing. And both his legs. His remaining limb - his left arm - was braced in a plaster cast. He couldn't move his swollen fingers.

"I was glad to be alive," said Bozik, 26, who learned after regaining consciousness at the Walter Reed Army Medical Center that his vehicle had detonated a land mine. "I was in a lot of pain but decided to deal with the problem I had then. I was an amputee."

For the U.S. military, it is a point of pride that a larger share of soldiers and Marines have survived serious injury in Iraq than in any previous war. But the flood of shattered survivors has presented a host of fresh challenges.

Come to Walter Reed and see a bustling microcosm of what the war has brought home - soldiers who have survived terrifying explosions but now must find ways to live with missing limbs or damaged brains.

"It's devastating," said Dr. William Doukas, chief of orthopedics at Walter Reed. "We're seeing mangled extremities with multiple open fractures, sometimes with amputations. And we're seeing a combination of injuries, more than one extremity involved."

For patients and those treating them, recovery means more than learning to walk on prosthetic legs. Or holding a toothbrush with mechanical hands that can't feel. Or organizing life's essentials - artificial arms, legs, wheelchairs or walkers - to make it safely from bed to bathroom.

It also means preserving self-esteem, finding understanding in a world where most people can't comprehend the horrors faced, or managing disturbing memories so they remind but don't torment.

"The toughest part is the emotional," said former Sen. Max Cleland, who lost two legs and an arm in Vietnam. "The problem comes when you're carrying this massive, incredible, life-defining experience. Only a select few will understand."

Through the end of last year, 90 percent of troops suffering serious injuries had survived their wounds, compared with 76 percent in Vietnam and 70 percent in World War II, according to the Defense Department.

Credit goes largely to ceramic-lined body vests, which protect the torso from bullets and shrapnel, and the remarkable speed of rescue, treatment and evacuation.

But protective equipment and the best military medical system ever created can do little to prevent arms and legs from being blown off by shrapnel containing nails and bolts or the brain from being injured by shock waves smashing helmet against head.

Statistics tell part of this story.

Six percent of injuries suffered by U.S. troops have involved amputations - twice the rate of recent wars, according to data included in the 2005 defense appropriations bill.

Through April, Army hospitals treated 240 amputees, 15 percent of whom lost two or more limbs, according to the Army. Data compiled by the Marines are incomplete, but the corps has suffered half as many casualties overall as the Army.

Also, a larger share of troops coming home from Iraq have suffered brain injuries, military doctors say.

More brain injuries

More than one in five soldiers and Marines treated at the U.S. military hospital in Germany suffered injuries to the head, face and neck, said an article last month in the New England Journal of Medicine. This rough proxy for brain injury is about double the rate seen in Vietnam.

The reasons are complex. In Vietnam, bullets and shrapnel were the leading causes of head injuries and were more likely to kill than injure. In Iraq, where bombs have been the weapons of choice, soldiers more frequently suffer blunt head trauma that can leave them confused, depressed or less able to move normally.

"The blast has not ... been a major mechanism of injury in past wars," said Dr. Louis French, a neuropsychologist at Walter Reed. The hospital has treated more than 500 brain-injured soldiers since the war began.

Double challenge

About half the amputees at Walter Reed have also suffered brain injuries, a challenging combination for patients and their caregivers.

It can be hard, for instance, to navigate on prosthetic legs without clear instructions from the brain. As a result, doctors sometimes delay fitting new arms or legs until recovering soldiers can better organize their thoughts.

Visitors to Walter Reed's occupational and physical therapy departments are struck with scenes both sad and inspiring.

Amputees teeter and sometimes bound across the floor with computer-guided graphite and titanium legs. The brain-injured practice tasks as deceptively complex as turning a pedal wheel with their hands.

Heartbreak is hard to miss, like that of a brain-injured soldier crying out in frustration when he can't will his hand to paint a simple picture. But camaraderie is everywhere, with soldiers well into recovery encouraging others who survived explosions just days earlier.

"Initially, everybody is gung ho - they are all motivated to get well and do what's necessary to speed through recovery," said Doukas. "It's hard to know how they are going to do 12 months, 18 months and two years down the road. That's the question worth asking."

Paddy Rosback, executive director of the Amputee Coalition of America, said soldiers and Marines face their hardest battles when they leave the "cocoon" of Walter Reed for the relative isolation of home.

"Let's face it, one of the things they tried to get out of when they joined the military was home. Now, they're going back there missing some very important parts of their body."

Joey Bozik said he wasn't escaping anything. He joined the Army to prepare for a future in federal law enforcement.

Then came Oct. 27 last year, when Bozik and two buddies joined a convoy out to inspect a bomb discovered at a Marine checkpoint. As their Humvee approached the spot and circled off the road, a tire rolled over a mine. The vehicle blew apart.

"All the shrapnel came through the floorboard onto my legs and my arms," said Bozik. "A Navy corpsman came running forward and pretty much saved my life."

Bozik was airlifted to a Baghdad hospital, where surgeons took his right arm below the elbow and right leg above the knee. In Landuhl, Germany, surgeons determined that his left leg couldn't be saved and removed it below the knee.

When he awoke at Walter Reed's intensive care unit, he took in the comforting sight of his mother, brother and future wife standing by his bed. Then, he looked around and saw what he was missing. This, he told himself, was no dream.

"I thought, I'm going to be OK," said Bozik. "I suffered no vital organ damage, which was very important to me. I know it's hard to believe, but I've been one of the most upbeat people around here. What am I going to do? I can mope, but what good is that?"

Many operations

Bozik has had so many operations - maybe 20 - that he can't remember the exact number. Besides removing three limbs, surgeons reopened wounds to wash and disinfect them. They inserted a plate in his wrist, rods in each leg and a plate in his right arm. They reconstructed his left knee and applied an apple-sized skin graft to his thigh.

His left leg has a plastic cuff that fits over the stump below the knee and a spring-loaded ankle that gives him the flexibility to step properly. The right prosthesis is a more complicated affair, a so-called C-leg with a computer-guided knee that constantly recalculates the spring and extension needed for an appropriate stride.


06-12-05, 07:15 AM
Bozik is getting used to the fact that he lacks the sensory input of a hand wrapping around a can or feet touching the floor.

"Normally, your brain says stand and your body does it automatically," said Bozik. "But my body doesn't do that. I have to remember to push this muscle and pull that one."

In occupational therapy, he practiced using his mechanical arm, which straps onto the stump below his elbow and has a five-fingered hand capable of grasping or turning from side to side. Sensors read muscle movements above the elbow and fire instructions to the hand.

"You come here to work on picking up things like a soda can," Bozik says, demonstrating his new skill without mishap.

A man of enormous optimism, Bozik has no intention of accepting limits. He plans to move to Colorado with his wife, Jayme, build a cabin and find work counseling veterans.

He does acknowledge thinking about what his former life in Wilmington, N.C., was like when he could hop on his Ducati motorcycle and ride off.

"It's not going to be the same when I ride the motorcycle again," Bozik said, proudly displaying a photograph of it. "But I'm going to try to make it as close to that as possible."

Robert Acosta, a former Army ammunitions specialist, said adapting to life with only half his right arm has been the easy part since returning home to Santa Ana, Calif., in January 2004.

Acosta said he still hasn't gotten used to people staring when he enters a room. He fights memories that trigger fits of anger. He awakens from dreams to find himself striking his girlfriend. He's even fought the urge to drive off the road.

'Roller coaster'

"I'm on a constant emotional roller coaster," said Acosta, 21. "I wake up some days and look at myself and I don't have a hand and can't walk. It's like, 'What the hell is wrong with me?'"

Four months after the war began, Acosta was driving in a Humvee when someone tossed a grenade into an open window. He reached between his legs to grab it, but it slipped out of his hands. When he grabbed it again, the grenade exploded.

Doctors amputated his right arm below the elbow and repaired his broken right leg. They considered removing his shattered left foot but chose to repair it with grafts and hardware.

"I kind of wish they amputated it because it hurts so bad," he said. "It's pretty much a dead foot."

He isn't terribly happy, either, about his electronic arm. Though he said it looks nice and can do amazing things, it's too cumbersome for everyday use. A while back, he threw it into his closet and hasn't used it since.

"They kept pushing it and pushing it and pushing it," said Acosta. "After a while, I'd just wear it to shut them up."

Acosta said he prefers a traditional prosthesis - metal hook and all - but has gone without that, too, because it irritates his stump. "Driving one-armed isn't hard," he said. "Actually, I stick my stump through the steering wheel."

Tyler Hall, an Army sergeant from Alaska, spent 2 1/2 months in a coma after a roadside bomb blew his truck apart near Tikrit in northern Iraq in August 2003. The explosion crushed his left leg, knocked out half his teeth and broke his spine in three places.

When he awoke at Walter Reed, he discovered that surgeons had removed his leg below the knee and rebuilt his face. A few weeks later, he began adapting to a prosthetic leg, which he uses without aid of a cane.

However, the mental recovery has come slowly.

An affable young man with a sweet smile, Hall said he has trouble concentrating and gets easily distracted by anything that crosses his field of vision. This was evident as he spoke to a reporter in the lobby of a hotel on the hospital grounds, his eyes darting nervously from side to side as other soldiers passed.

Hall said he finds it hard to read and suffers from dark moods and fits of anger. He often forgets what was said to him minutes earlier, but he has a nice way of asking people to repeat themselves.

"When you start off with a head injury, most of the time you're so bad off you don't really know what's wrong," said Hall. "If you're not aware of what's going on, you don't really know what to correct."

Awkward situations

Hall, who also hopes to counsel veterans, has returned to Alaska a few times, where he has felt the awkwardness of meeting old friends. It's sometimes hard to follow conversation. He struggles not to resent people who cannot comprehend what he's been through.

His mother, Kim Hall, said her son has responded heroically to his injuries - running up a flight of stairs, for instance, just a few weeks after receiving his prosthesis. But she acknowledged that the war has robbed him of things hard to replace.

"Just being 23, normal 23-year-old stuff," she said "Having to get used to having a prosthesis and dating. He wants to go to school, but with this memory-loss thing it's going to be a little difficult.

"With the right support, he'll make it through."