Homecoming ~ Caring for a new generation of soldiers
The explosion came from his left.
Black.
Silence.
Capt. Jonathan Pruden tried to steer the Humvee to a stop as it slid along the road in Eastern Baghdad. He couldn't see through his left eye. His left arm didn't work. His legs didn't work. He couldn't hear, and something sprayed against the windshield. For a second, he thought the roadside bomb must have hit the vehicle's hydraulic line ... until he remembered there wasn't a hydraulic line there. It was him, his blood spraying the windshield.
"I have the wonderful distinction of being one of the first IED (improvised explosive device) casualties over there," says Pruden, now a retired U.S. Army officer who was injured July 1, 2003, just five months after the U.S. invaded Iraq. "I was in a softskin Humvee. No doors. I caught 173 pieces of shrapnel and one bullet."
Twenty operations and seven hospitals later, Pruden still has 153 pieces of shrapnel inside his body, including one chunk lodged near his spine and tiny flecks embedded in his skin and eyelid. Surgeons amputated his right leg below the knee in 2005, and he still feels pain from the softball-sized hole that was in his back. His left foot lost a toe, and he suffers from nerve damage there.
More than 30,000 U.S. soldiers have been wounded in Iraq since the beginning of combat operations there in 2003, according to the Department of Defense. Like Pruden, more than 13,000 of these soldiers never returned to combat.
It's the first major influx of returning soldiers to the United States since Vietnam, yet a lot has changed since then. Because of improved medical techniques and technology, more soldiers are surviving what were once considered fatal injuries. And because of the increased use of IEDs, also known as roadside bombs, veterans are returning from Iraq and Afghanistan with multiple wounds and traumatic brain injuries.
"The signature injury of this war is traumatic brain injury due in part to remarkable advances in battlefield medicine," says Bradley Bender, M.D., chief of staff of the North Florida/South Georgia Veterans Health System and a UF professor of medicine. "Previous wounds that would have been lethal no longer are.
"The country is responsible for these people," he adds. "The cost of ongoing veterans' care will probably exceed the amount it costs to fight the war itself. If you look at the history of military injury, up until Vietnam, the ratio of injuries did not exceed two to one. Now, the ratio is eight injuries to every death."
Casualties are down now in Iraq — although they are up in Afghanistan — and leaders are pressing to withdraw troops within the next 16 months, but the more long-term task of caring for today's wounded soldiers is still only in its infancy. It's a journey that begins on battlefields and moves from combat support hospital to military hospital to rehabilitation clinics to Veterans Affairs medical centers and even to the private sector.
Although UF is not directly involved in caring for wounded soldiers and veterans, its faculty members are, serving in battlefield and military hospitals, in VA medical centers and in labs, looking for the best ways to rehabilitate warriors wounded in service and improve the lives they will lead after war.
"We draw on the expertise at UF, and we would not have as successful a program as we have without that affiliation," says Paul Hoffman, M.D., associate chief of staff for research with the North Florida/South Georgia Veterans Health System and a UF research professor of neuroscience. "We could not exist as a health-care facility that does this kind of high-quality health care and research if we did not have the University of Florida right across the street."
Over there
The next thing Pruden remembers after the blast is lying in a pool of warm liquid on the ground outside the Humvee. Motor oil, he thought. It was blood. Fellow soldiers placed tourniquets around his legs to stop the bleeding and lifted him into a truck to get him to a doctor.
After an initial stop at a soccer stadium where a physician's assistant covered his eyes — one of his corneas was cut — and started an IV while he lay on a card table, Pruden was flown in a Black Hawk to the closest combat support hospital, where doctors began operating.
These mobile medical centers are the primary line of defense for treating wounded soldiers. After undergoing initial surgeries and treatment here, soldiers with more extensive injuries are then flown to military hospitals in Europe and eventually back to the United States.
The rooms are air-conditioned tents, with operating rooms set up in prefabricated buildings, and because of the sand, everything tends to be dusty, remembers Lt. Col. Robert Redfern, M.D., a UF professor of anesthesiology at the College of Medicine-Jacksonville.
"The conditions were somewhat primitive, but the medical care provided was outstanding," says Redfern, who served in the 345th Combat Support Hospital in Tikrit in 2008. "The equipment is as good as we have here. They had everything you would need to run a community hospital, a lab, CT scanners, everything."
Although in his 50s, Redfern decided to join the U.S Army Reserves in 2007. It was something he'd always thought about doing. He admires soldiers, he says. His father had been a fighter pilot in World War II, and his brother spent 20 years in the U.S. Army. With two wars and soldiers in need of medical care, he decided it was time.
Several UF faculty members in Gainesville and Jacksonville have served since the wars in Afghanistan and Iraq began. Others, including Jacksonville doctor Eric Frykberg, M.D., have traveled to Germany to work at Landstuhl Regional Medical Center, a military hospital where many wounded soldiers are taken for surgery.
It was July and 134 degrees with a 30-mile-per-hour wind when Redfern first glimpsed the Middle East, stepping off the plane in Kuwait, where he and his unit stayed before heading to Iraq.
"It's not like being in another country, it's almost like being in another world," he remembers. "The main impression I had, it really makes you grateful for what you have in this country, the freedom, the safety, the fact that you can go to the market without worrying about a car blowing up next to you."
At the combat support hospital where he and fellow College of Medicine-Jacksonville orthopedic surgeon Col. Hudson Berrey, M.D., worked, there were days when they didn't do anything, and days when they spent hours tending patients.
At these hospitals, doctors treat patients suffering from typical conditions, such as appendicitis, and perform emergency operations, stabilizing soldiers so they can be flown to hospitals such as Landstuhl, says Berrey, a retired U.S. Army doctor and former chief of orthopedics at Walter Reed Army Medical Center who was recalled to active duty. They also care for Iraqi soldiers, although not as often now.
"One of the benefits for me is the Army has always been the cutting edge of trauma care," Redfern says. "I learned some things that are going to be applicable to patients we take care of here."
Throughout history, combat has sparked numerous medical innovations that save lives in battle and eventually help civilians, too. In this war, doctors are using new types of tourniquets and other technologies and have developed better techniques for fluid replacement and managing blood loss.
"Each time we have been in a military conflict there have been significant advances to come out of it," Berrey says.
Back here
For some wounded soldiers, one of the most difficult parts of the journey begins after they leave the military. Transitioning to everyday life can be stressful, particularly for veterans struggling with disabilities and conditions such as post-traumatic stress disorder and traumatic brain injury, Pruden says.
Now living in Gainesville with his wife and daughter, Pruden spends a lot of his time talking with veterans as an outreach coordinator for the Wounded Warrior Project, a nonprofit veterans' service organization. It's a job he describes as part patient advocate, friend, lobbyist, mentor and counselor.
"Most of (veterans') physical needs are met, the medical care is great in the Department of Defense and VA," he says. "There's a huge population of people with TBI, PTSD and substance abuse problems. That's where the VA and DOD are going to probably spend and should spend most of their resources. The programs for substance abuse, homelessness and PTSD are woefully inadequate."
The need for more mental health services is not news to Bender, who, as chief of staff, oversees clinical operations at one of the largest veterans health systems in the country. Bender and Mark Gold, M.D., chair of UF's department of psychiatry and an addiction medicine expert, are in talks to get more psychiatry residents working with patients at the VA.
"It's a confluence of a major need in the state — there's a terrible shortage of psychiatric and addiction specialists — and having returning vets with so many substance abuse, depression and trauma problems," Gold says.
The VA is also adapting to the new generation of veterans, Bender says. Approximately 7,200 of the North Florida/South Georgia VA's 125,000 patients last year were veterans of Iraq and Afghanistan, a proportion that will increase as veterans age and require more medical attention. Because younger veterans have different needs, the VA is offering more evening hours and mental health clinics and is expanding electronic communications so patients have easier access to their records, he says.
Although VA medical centers like Malcom Randall are considered leaders in patient safety — barcodes match medications to patients and electronic medical records have been used there for 10 years — perhaps one of the most interesting aspects of the hospital occurs in labs scattered around its campus.
In the lab
In the VA's Human Motor Performance Laboratory, Linda McDonald strolls at an even pace, smiling as her feet brush the moving treadmill and swinging her arms wide. McDonald isn't a soldier. She broke her neck when she fell off a horse. But her participation in a trial of a type of therapy called locomotor training could help future soldiers and civilians with spinal injuries relearn how to walk.
"About 75 percent of our VA-funded research focuses on some aspect of rehabilitation, and that includes basic science of the nervous system as it relates to rehab in spinal cord injury or traumatic brain injury," Hoffman says. "The spectrum of research in the VA is broad and multidisciplinary, from studying causes and disease pathogenesis through drug intervention and rehab intervention and then studying systems of health-care delivery. It allows for a great perspective on the issue of diseases and how you deal with them in the U.S. In some senses, it's a microcosm of world health."
Nearly all of the doctors at the VA medical center in Gainesville hold dual appointments with UF, and several researchers in the colleges of Medicine and Public Health and Health Professions do, too, Bender says. The center actually houses the second-largest rehabilitation research program in the country, Hoffman adds.
UF researchers have recently strengthened their focus on studying rehabilitation for wounded soldiers with the formation of the Florida Trauma Rehabilitation Center for Returning Military Personnel. The center's research includes everything from physical therapy researcher Andrea Behrman's studies of locomotor therapy to treat spinal cord injury to studies examining the use of robotics to improve hand function and exercises to relieve lower back pain.
"I think the big concept is quality of life," says William Mann, Ph.D., chair of occupational therapy in the College of Public Health and Health Professions. "In rehabilitation, we are looking for ways to help people improve their quality of life and have full participation."
Craig Velozo, Ph.D., UF's associate chair of occupational therapy and a VA researcher, is developing a computer-adapted test that could help doctors better assess patients for traumatic brain injury. All soldiers are now tested for traumatic brain injury after returning from service, but these tests often aren't applicable to everyday life, Velozo says.
As part of a National Institutes of Health-funded study, Velozo developed a computer-adaptive test — which presents questions based on previous answers — that in five questions can pinpoint what daily tasks people can handle according to their cognitive capabilities. The technique was presented to Congress as part of a report on the future of injury assessments.
"We have done this with more severe TBI; now we want to assess on people with mild TBI, the higher-end people," Velozo says.
Pacing in front of a downtown Gainesville building after a long day of meetings, Pruden talks rapid-fire on his cell phone. It's a veteran he's been trying to help get a house. As he shifts from one leg to another, no one would know one of those legs is a prosthetic. No one can see the wounds on his other foot or even the tiny shards of shrapnel embedded in his skin.
Eventually he hopes he doesn't have to take calls like this. Not that he doesn't like it. He loves helping veterans, and he's good at it. He just longs for the day when there won't be a need for his job.
"We are already seeing fewer casualties in Iraq," he says wistfully. "But it seems like as we see fewer there, there are more coming from Afghanistan. But hopefully, there won't be a need for me to do this soon. That would make me very happy."