The doctor begins with an apology because the questions are rudimentary, almost insultingly so. But Robert Warren, fresh off the battlefield in Afghanistan and a surgeon's table, doesn't seem to mind.
Yes, he knows how old he is: 20. He knows his Army rank: specialist. He knows that it's Thursday, that it's June, that the year is 1020. Quickly, he corrects the small stumble: "It's 2010." He knows that his wife is Brittanie, that she's due with their first child any day now, and that they "got married two to three weeks before I went to that country."
Stumble No. 2: "That country."
David Williamson doesn't let it slide. "Which country?"
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"Whatever country it was that I got blown up in," Warren says.
In a conference room at the National Naval Medical Center in Bethesda, Md., he purses his lips, and as he searches for the word "Afghanistan," he slides his hand over the left side of his head, which is cratered, like an apple with a bite taken out of it.
"Crap, I can't remember," he says finally.
Warren has trouble remembering a lot of things. Which isn't surprising, considering that several pieces of shrapnel tore through his skull after insurgents outside Kandahar blew up his truck with a rocket-propelled grenade in May. One piece came to rest in the center of Warren's brain — two millimeters from his carotid artery — where it remains, suspended like a piece of fruit in a gelatin mold, too dangerous to extract.
"I'm going to say three words and then have you say them back to me, OK?" says Williamson, a neuropsychiatrist who runs Bethesda's traumatic brain injury unit. "Apple. Desk. Rainbow."
Warren doesn't hesitate: "Apple. Desk. Rainbow."
He seems satisfied to have answered a question correctly. But repeating the words immediately isn't the point of the exercise; it's being able to repeat them in 10 minutes or so, after some other tests.
A person with normal cognitive function will probably remember all three words. Patients with mild Alzheimer's might recall two. People with advanced dementia might remember only one, or none at all.
At the Bethesda hospital, the flow of brain-injured patients is constant. For nearly a decade, the United States has been fighting wars in which soldiers are routinely exposed to brain-rattling blasts that can send ripples of compressed air hurtling through the atmosphere at 1,600 feet per second. Now, the military is struggling to come to terms with an often-invisible wound.
The military brass are discovering that what used to be shrugged off as "getting your bell rung" can lead to serious consequences. In some cases, even apparently mild brain injuries can leave a soldier disqualified for service or require lifelong care that critics say the Department of Veterans Affairs isn't equipped to handle.
Since 2000, traumatic brain injury, or TBI, has been diagnosed in about 180,000 service members, the Pentagon says. But some advocates for patients say hundreds, if not thousands, more have suffered undiagnosed brain injuries. A Rand study in 2008 estimated the total number of service members with TBI to be about 320,000.
A small percentage of those injuries are as serious as Warren's. To let his brain swell and keep the blood flowing, thereby preventing the damage from worsening, doctors removed virtually the entire left side of his skull, a procedure known as a craniectomy.
Warren's physical wounds will heal, but three weeks after he was hit, military doctors are still discovering the extent of the damage.
Williamson plows ahead with other tests, revealing that Warren doesn't know where he is. "This is the U.S.A.?" he says. Warren cannot subtract seven from 135, but he can spell "world" — though not backward. He can recite the days of the week but can't come up with the words for necktie or button.
Finally, Williamson asks whether he can remember those three words he had to repeat. Sixteen minutes and 19 seconds have passed.
"Which words?" Warren says.
The patients on 7 East
No two traumatic brain injuries — signature wounds of the wars in Iraq and Afghanistan — are the same, but the patients on 7 East, Williamson's TBI unit, demonstrate what life is like when the organ that turns a body into a person is damaged.
There's the Marine whose injury robbed him of the ability to understand speech even though he could still read, another who could no longer laugh, one who could see out of both eyes but only to the left, and one soldier who became dangerously impulsive and started spending thousands of dollars on junk he didn't need.
Although their injuries might not be as visible as a severed limb, TBI victims' damaged neurons and altered brain chemistry can cause all sorts of behavioral problems.
Those injuries are about much more than a lump of tissue sitting between the temples. "It's about who they are," Williamson says. "How they see the world. How they process different experiences. It's about how their personality changes. It's about their humanity."
Severe TBI, such as Warren's, can lead to wholesale personality changes. But doctors now know that even mild TBI can have serious consequences. A blast "causes a change in how your brain functions," said Vice Adm. Adam Robinson, the Navy surgeon general. "People have been very, very slow to come to that conclusion, but it's true."
Established after trauma surgeons realized their brain-injured patients needed additional help, 7 East, one of the few units dedicated exclusively to TBI, is less than two years old. Patients usually land in the hospital's trauma unit first, but if they show any sign of cognitive impairment there — can't remember where you went to high school? —Williamson has authority to transfer them to his unit.
Veterans Affairs Secretary Eric Shinseki said in August that the military and the VA "simply cannot afford to be less than aggressive in our effort to identify, treat and rehabilitate TBI victims."
Williamson's unit, which can handle six patients, is a first, but insufficient, step. Next month, a $65 million medical center devoted to TBI, post-traumatic stress disorder and other psychological problems will open its doors at Bethesda; it will eventually treat about 20 patients.
But the military's awakening to the severity of traumatic brain injury comes nine years after the flow of victims began.
Critics such as Cheryl Lynch, founder of American Veterans With Brain Injuries, say the delayed response is nothing short of a dereliction that has left severely injured veterans suffering for years. Her son, Chris Lynch, a former Army private who hit his head after falling 26 feet in a training exercise 10 years ago, was in and out of hospitals for years before getting treated at 7 East in the spring.
"The only appropriate place I know to send families for brain injury treatment is to Dr. Williamson," Cheryl Lynch said. "That's sad."
A rose is a telephone
After seeing Williamson in the morning, Robert Warren has an afternoon session with his speech therapist, who proudly tells him he's "come a long way" — quite an understatement considering Warren arrived in Bethesda on a ventilator and in a coma from which he didn't emerge for five days.
But now, just three weeks after he was hit, he denies any problems with speech or memory: "I say everything just like I did before I was in that country."
He still can't recall the word "Afghanistan," but he does know he's at the Bethesda naval hospital. Answering the therapist's rapid-fire questions, Warren demonstrates that he also knows that the door is closed, that the light is on, that paper burns, that he's not wearing red pajamas. But soon his concentration fades, and he slips.
"Do you eat a banana before you peel it?" she asks.
"Does it typically snow in July?"
Then the therapist shows him a rose and asks what it is.
"This would be a telephone," he says.
It hurts his family to see him like this, but they're mainly happy he's alive. When she first got word that Robert had been wounded, Brittanie, then eight months pregnant, collapsed. Her father took the phone and was told that the only thing they knew about Robert was that they didn't know whether he would live.
Now, amazingly, Warren, speaking with his same Arkansas drawl, shows flashes of his old self. When Brittanie tells him he's "full of it," he smiles, tickles the top of her head and says, "Yeah, full of Southern pride."
When Warren holds his daughter for the first time at the naval hospital, his father-in-law asks what it feels like to be a dad. It's a simple question, but given the situation, a loaded one: Will Robert be able to care for the bundle in his arms? What will life be like when there are no more nurses and doctors tending to him around the clock?
"I don't know yet," he responds.
'The real test'
One month after getting hit, Warren remembers the word "Afghanistan." He remembers Kandahar. He remembers the moments before the rocket blew up his truck.
"I've seen tremendous improvement," his mother, Susan Bryant, tells Williamson during a meeting at the hospital.
"You really are doing very well," Williamson agrees.
But memory, language and the ability to think clearly — up to now the focus of his rehab — are not the only problems Warren might encounter. "There's one other area that's on my radar," Williamson tells Warren and his family. The area of the brain that's injured "is also involved in emotional regulation."
"In severe cases, we have some patients who get manic-depressive mood swings or they get profound depression or they have temper outbursts," the doctor warns.
In other words, Warren could require round-the-clock supervision. There's no way to tell. Some erratic behaviors might not show up for months or years, Williamson says. Warren and his family must wait and see how he does at home, where he'll face everyday challenges: getting a job, soothing a crying baby, remembering appointments, managing money.
"The real test," Williamson says, "is real life."