Rebuilding bodies and mending minds


By any reasonable standard, James Vandenheuvel shouldn’t be alive, much less lounging in a room at the Wildwood Inn in Woodbury, watching television and bantering with his mother, Mary Alden.Vandenheuvel, who shares a home with his mother in Sartell, Minnesota, was in town for outpatient treatment at the Minneapolis Veterans Affairs (VA) Medical Center’s Polytrauma Rehabilitation Center (PRC), where, from August to October of 2004, he was an inpatient.

The PRC was created specifically to rehabilitate American servicepeople injured in Afghanistan and Iraq. Like James, nearly all patients at the PRC have suffered traumatic brain injury (TBI) along with numerous other combat wounds, from burns to multiple compound fractures to traumatic amputations of one or more limbs, to blindness, deafness, and more. Almost all are victims of some kind of explosion, either from rocket-propelled grenades (RPGs) or, more commonly, from the unsophisticated-but-nonetheless deadly improvised explosive devices (IEDs) that have become one of the Iraqi insurgency’s weapons of choice.

Not quite two years ago, debris from an IED explosion crushed the 25-year-old Vandenheuvel’s lower body and cleaved his skull like a medieval battleaxe. In the months following, doctors at Walter Reed Army Medical Center in Washington, D.C., quite literally brought him back from the brink of death on numerous occasions. Upon his transfer to the Minneapolis VA, his prognosis was not promising: He was expected to survive, but his doctors predicted that he might never be able to get out of bed or feed himself, let alone walk. Today, only his peculiar rocking gait and the jagged scar nearly hidden by his sand-colored hair, or the look of mild confusion that sometimes passes over his face, betray the hell he has been through. Those physical reminders, and the combat-weary tone in his mother’s voice, for she has accompanied him on the road to recovery every step of the way.

“I still remember the first time [after his injuries] he stood at the toilet to pee,” Alden recalls with grim humor. “It’s like having a child all over again. He’s had to learn how to do everything all over again—how to walk, how to use his muscles. All of it.”

One Soldier’s Story
Although everyone associated with the VA’s PRC will tell you that there is no “typical” patient, James Vandenheuvel’s experience is probably as representative as any.

The former security guard and law enforcement student at Alexandria Technical College joined the Minnesota Army National Guard in 2000, never expecting to be deployed in overseas combat. He later transferred to the California National Guard when he moved to the West Coast to be near a former girlfriend.

In March 2003, he and his unit were deployed to Camp Bucca, just north of the Kuwait border, to provide protection for American troops. After a few weeks’ leave later that year, he returned to Iraq in December, this time stationed at a military base outside Abu Ghraib.

It was there as a gunner with a Quick Reaction Force—a unit sent out to patrol the streets around the encampment in order to provide protection for American troops—that, in his words, “I was blown up.” Not surprisingly, Vandenheuvel doesn’t remember much of what happened; most of what he knows comes from what he was later told by other unit members.

“We were on patrol keeping an eye out for RPGs,” he says. “One member of the company was having a birthday and was taping everybody in the unit to send home to his son. That’s the last thing I remember.”

At some point during the patrol, the unit’s lead vehicle was struck by an RPG and small-arms fire. No one was hurt. The vehicle Vandenheuvel was in was not so lucky. An IED constructed of artillery shells exploded, blowing the vehicle into a ditch and killing the driver. The force of the explosion blew Vandenheuvel up into the gun turret, then sucked him down into the interior of the vehicle. A 500-pound armored door landed on top of him. Vandenhuevel suffered shrapnel wounds, pulmonary contusions, a crushed femur, severe soft-tissue damage to his right calf, and a head injury that, in his mother’s words, “laid his skull open, so his buddies and the medics could look right down into his brain.”

It is one of the grim ironies of the Iraq conflict that, because of improvements in emergency medical care, soldiers like Vandenheuvel, who would undoubtedly have died of his wounds during an earlier war, survive. But they often face lifetimes of terrible disability; some brain-injured victims never wake up.

In that regard, Vandenheuvel was one of the luckier ones, if it is possible to speak of luck under such circumstances. Medics appeared on the scene within 15 minutes of the attack. Screaming in agony from his broken leg, Vandenhuevel was airlifted to a military hospital in Baghdad, where surgeons performed an emergency craniotomy, removing a portion of his damaged skull, and inserted a titanium plate in his head in order to relieve pressure from fluid on his brain. He was then flown to Landstuhl Regional Medical Center in Germany, via Kuwait, and immediately transferred from the military hospital there to a nearby university medical center, where he was kept in a medicated coma for a week while doctors sought to stabilize his condition. A month later, Vandenhuevel was transferred to Walter Reed. Two days later, he almost died. His cerebral pressure was elevated and he was suffering pneumonia brought on by the pulmonary contusions.

Vandenhuevel remained at Walter Reed from March 12 to Aug. 11, 2004, spending all but one month in the ICU. Several times he came within a whisker of dying, when for some reason he proved unable to withstand even normal levels of cerebral pressure. His mother was with him the whole time, taking leave from her job as a health unit coordinator at St. Cloud Hospital.

“At Walter Reed, his doctors thought that I should put him into subacute care—basically a nursing home—but I refused to let them do that,” Alden says. “I’d take him home instead and care for him myself before doing that.”

Mending Body and Brain
Like virtually everything else associated with the invasion and subsequent occupation of Iraq, the scale and mix of casualties sustained by American forces has differed considerably from early projections.

Originally, the Pentagon expected few casualties (televangelist Pat Robertson has even claimed that just prior to the invasion President Bush reassured him that there would be no casualties). However, as the Iraqi insurgency began to take shape in the spring and summer of 2003, the Pentagon believed, based on early casualties, that the bulk of soldiers shipped home for treatment of serious wounds would have suffered traumatic amputations.

But as the insurgency turned increasingly to IEDs, it became clear that many troops would be returning stateside with TBI, as well as multiple associated injuries, including blindness, deafness, multiple compound fractures, soft-tissue damage, traumatic amputation, and internal injuries, as well as a host of psychological problems ranging from post-traumatic stress disorder and combat stress to behavioral and mood disorders triggered by their brain injuries. They would also have to adjust to a life of disability.

Traumatic brain injury refers to any trauma that damages brain tissue and is not caused by a natural event such as a stroke. Its symptoms can range from being nonresponsive or minimally responsive to being awake and alert yet having residual motor, cognitive, psychological, and personality changes. Military and VA doctors are seeing many more cases of TBI coming out of Iraq because soldiers are outfitted with better protective gear than during previous wars. For example, plate armor protects their torsos, allowing them to survive injuries inflicted by IEDs and other explosives that send out shrapnel, and Kevlar helmets protect them against projectiles but not against concussive injury. Among TBI outpatients, the most common long-term symptoms are depression, mood swings, anger, problems with short-term memory and information processing, and difficulty understanding social context.

In response to the changing circumstances on the ground in Iraq, Congress in 2004 authorized establishment of four officially designated PRCs in the United States: The VA Medical Center in Minneapolis is one of them. The Minneapolis PRC opened in February of last year after just a few months of preparation, consolidating services and professionals already employed at the VA and bringing on additional staff to create a comprehensive multidisciplinary team to care for the war wounded. For example, the VA added case managers to meet Congressional requirements that one case manager be assigned to no more than six patients at a time—a reflection of the complex medical care required by patients as well as the equally complicated paperwork that patients and their families must wade through, especially as a serviceperson moves from active military to veteran status. Because the unit draws on resources already at the VA, Minneapolis VA officials were unable to say exactly how much money has gone toward the creation of the unit.

“This effort had to be ramped up pretty quickly,” observes Barbara Sigford, M.D., the Minneapolis VA’s director of physical medicine and rehabilitation. Sigford has been with the VA for 14 years; as a specialist in TBI, she was the natural choice to lead the new unit.

As the Iraqi insurgency gathered steam, the Minneapolis VA has seen between 30 and 40 TBI patients come through its wards in a year—up from about 20 the year before the start of the conflict in Iraq. These new patients are unlike Sigford’s former TBI cases, most of whom were veterans or active service personnel injured in non-service-related accidents. “The big difference between the kind of [TBI] patients we were seeing before and those coming to us now is that we are seeing brain injuries associated with a lot more other injuries—fractures, visual and orthopedic problems, burns, and significant mental health issues,” she says. “The other component is family and the family stress we see.” Many family members have been by the patient’s side since he or she arrived at Walter Reed or the National Naval Medical Center in Bethesda, Maryland—the two facilities where seriously injured personnel are sent when shipped home from Iraq or Germany.

This month, as part of the evolving response to the Iraq conflict, the VA’s PRC, which had treated patients in two separate units in the medical center, was consolidated into one location. The new space includes an independent-living unit intended for use by patients transitioning from inpatient to outpatient status (the living units can also be shared with family members or other caregivers who will go on to work with the patient after he or she leaves); a new, more comfortable lounge for the many visitors who end up spending a lot of time at the VA; recreational facilities; upgraded computer resources for staff; a pharmacy stocked with the kinds of pain and seizure medication often required for TBI victims; and a library offering patients and families educational material about brain injury rehabilitation. The new space also consolidates the unit’s acute and subacute facilities. Ancillary services, such as food service, have been altered to cater to the tastes of patients who are generally younger than those treated at the VA prior to the wars in Iraq and Afghanistan.

The unit’s redesign also includes another less tangible component, one intended to lessen the often acute anxiety injured service people feel, especially in the early stages of their recovery. Such anxiety can affect their health and lead to depression as they begin their lengthy rehabilitation process. “We have integrated more concepts and environmental cues from the military to decrease the separation anxiety troops often experience because of loss of contact with their units,” Sigford explains. One way physicians and therapists do that is by addressing patients using their rank, which is not common at the VA, where most patients are no longer on active duty. Another way they try to keep patients in the PRC feeling connected is through the presence of a full-time on-site military liaison. Sgt. 1st Class Luis Osorio, who has been assigned to the unit since September, helps patients make the transition by making sure their paperwork is in order, that their personal belongings arrive at the VA, that their financial needs are being met, and that they know about services and resources available to them. Osorio also helps patients’ families navigate the system and makes sure the agencies relevant to the injured service member know that he or she is at the VA.

As important, is the emotional support Osorio lends as he tries to reassure patients that they have done as much as any soldier or Marine could. “My being here has a positive impact for the service members because they see a uniform,” Osorio explains. “The only thing I’ve gotten is smiles from patients—‘Oh, there’s active-duty military here.’”

When Vandenheuvel was admitted to the PRC, he immediately began a rigorous course of rehabilitation that included physical and occupational therapy, speech therapy, recreational therapy, and regular meetings with a psychologist. At first, he was being fed through a tube and suffered from incontinence; he now not only feeds himself but can cook as well, and he no longer has problems with incontinence. He also had trouble regulating his mood, a typical symptom of TBI.

“I’d get ticked off just like that,” he recalls. “One time I got so mad, I punched myself in the face. Afterward I laughed my butt off about it.”

During his inpatient stay at the PRC, his treatment program changed to reflect his progress. “What I really liked was that if your [treatment] goals change, they’ll change the therapy to what you want and need,” he says.

The Long Journey Home
The range of injuries and prognoses for PRC patients—from an independent, self-sufficient existence somewhere down the road to a lifetime in a long-term care facility—as well as the need to service a patient population that, in the nature of rehabilitation, is at varying stages of recovery, necessitate a particular approach to care.

Upon admission, each patient is assigned a PRC team that includes a physiatrist, rehabilitation nurses, speech language pathologists, occupational therapists, physical therapists, therapeutic recreation specialists, social workers, psychologists, and a low-vision specialist. As needed, the team might be expanded to include others such as an audiologist (many patients like Vandenheuvel return with significant hearing loss caused by explosions), an orthopedic surgeon, a psychiatrist, and a neurosurgeon.

Recognizing that the families of injured patients are themselves suffering from enormous stress while also playing a key role in helping their loved one with rehabilitation, the PRC staff incorporates families into the treatment program and provides them with help, including a chance to consult with a staff psychologist (see “A Mother’s Advice”).

“Caregiver and family support and education are very important components of what we do here,” says Larisa Kusar, M.D., the PRC’s medical director and lead physician for inpatients. “Our psychologist might be seeing a patient every day while also helping the patient’s family, too. This is also why we have a case manager involved with the patient and communicating with the family and/or the patient and working closely with them right through discharge and beyond, walking them through the benefits they are eligible for, helping with problems that arise with moving, and just generally dealing with a complex system at a time when families are already dealing with a lot of stress.”

That stress, of course, predates the arrival of patients at the VA’s PRC. Many family members have already spent weeks, even months, at the bedside of a patient at Walter Reed or Bethesda, during which time the patient may have experienced, as did Vandenheuvel, numerous brushes with death. Even the shift from those hospitals, where patients are likely to receive visits from the president or sports and entertainment celebrities and where patients’ families might be treated to dinner in, say, Bethesda’s Admirals’ Dining Room, to the months of difficult, often painful work at the PRC can prove to be a shock.

“Patients come here to work and to work to increase independence,” explains Rose Collins, Ph.D., L.P., one of the PRC’s psychologists. “We will often want families to step back and not do things for patients that they are trying to learn how to do for themselves. What I focus on in my work with families is to educate them about the rehab process and to get them to trust it, so they know it’s OK to leave for a while, that part of learning is to make mistakes, so patients need to try things and sometimes fail, but within a supportive environment.

“At the same time, it’s important for families to be present and to witness the cognitive and psychological impairments in action so they will be able to come to understand what the patient is dealing with.”

And with TBI, the long-term cognitive and psychological impairments can range widely, from relatively subtle deficits to disabilities so severe that the patient will need round-the-clock care for the rest of his or her life.

“TBI patients face a range of challenges,” Collins says. “First, there are the cognitive impairments. They often have problems with memory, problem-solving, information-processing, emotional regulation, and learning new information. We often see problems with higher-order cognitive functions—like abstract reasoning and the rules of social interaction.”

Along with the cognitive impairments come mental health issues, in particular depression and anxiety. These can stem from two origins: neurological disruption, especially in the connections between frontal and medial lobes that regulate mood, caused directly by the injury; and, indirectly, in response to a patient’s growing awareness that life has changed irrevocably.

“With TBI, there’s often a change in the sense of self-identity, of self-esteem,” Collins says. “With a lot of the younger guys, their identity was tied to physical prowess or leadership abilities or their warrior skills. Now they have trouble remembering, sequencing behaviors, problem solving; they have physical disabilities. One of the tasks we have to work on is developing new asset-valuation, new ways to achieve the same ends they care about—like leadership or helping others or providing for their families—but in different ways.”

Adjusting to these new realities takes many patients and their families through a process akin to the stages of grief that accompany the death of a loved one. The loss for most of the PRC patients is what Collins calls “ambiguous loss.” It does not lessen and may be even more difficult to come to grips with than the loss felt after a death.

“I had one parent in a family meeting say, ‘I sent over a young son in perfect condition and this is what was sent back,’” recalls Cindy Hintz, one of the PRC’s social work case managers. “Of course he would never say something like that to his son, but it’s true. When these patients went over to the Middle East, they were in perfect physical and mental condition. Now they are not.”

Perhaps surprisingly, the long-range prognosis for the PRC’s patients rests as much on the cognitive impairments caused by their injuries as it does on the extent of their physical impairment. In part, that is because of the way the world-at-large responds to these different forms of impairment. If a veteran has lost a leg or an arm, it is immediately apparent to strangers. If, on the other hand, he suffers psychological or cognitive impairment, people may not be so understanding or as willing to make accommodations.

Problems with what therapists call “social pragmatics,” the ability to adapt language to various social situations, is one such subtle challenge even a high-functioning outpatient such as Vandenheuvel faces. “We all have a mental editor that dictates how we speak to different groups,” says Hintz. “Before his injury, a patient here would have instinctively addressed his military buddies differently from ladies at a church social. But as a result of their injuries, many patients are unable to make those kinds of appropriate choices. It’s a very subtle handicap.”

And because this kind of handicap is subtle—and all but invisible—it poses a special difficulty for patients trying to assimilate back into society. As Hintz says, the “general population is aware of the deaths [of American soldiers and Marines in Afghanistan and Iraq] but not about the people who return injured and what it costs them.”

Collins says she’s had many patients, especially those further along in their recovery, who’ve told her that they would give an arm rather than have to deal with the mental impairments or that they wished they had a scar on their heads so people would understand. “It’s hard when there is no physical impairment that’s visible, because then people tend to think that the patient is rude or lazy or doesn’t care what others think.”

‘A Helluva Road’
According to Sigford, the VA’s PRC, has “a pretty good record of getting 80 to 85 percent of our patients back home,” although a majority of those patients will suffer long-term after-
effects of their wounds.

Still, given the kind of life-changing injuries and the youth of those treated at the PRC, where the average age of patients is 28, both she and Kusar admit that working on the unit can present special challenges to the staff as well as to patients and their families.

“It is stressful at times,” Kusar says. “But as a team we really come together and try to figure out how to help patients as much as we can. We focus on improving their quality of life in any way we can.”

And it’s always gratifying, Sigford says, “when a patient comes in and is unconscious or unable to move and they end up walking out. At least in a rehab unit, we know we are on an upward slope with our patients.”

For James Vandenheuvel, the path back home has been difficult—and there’s no end in sight. Medically retired from the Army in February 2005, Vandenheuvel has made his rehabilitation his full-time job. One day a week, Vandenheuvel comes to the VA in Minneapolis as an outpatient to work with a physical therapist and a speech pathologist; three times a week, he goes to the St. Cloud VA to do therapy in the pool for his leg; he also does rehab exercises on his own.

Vandenhuevel is able to shop, pay his own bills, do his laundry, clean, and drive. He speaks clearly, but sometimes interjects the wrong word or a profanity, has problems with short-term memory, and cannot stand or sit for more than half an hour because of the discomfort. Although he’s come far, his prognosis remains uncertain.

“I don’t know how long he’ll continue to get better,” says Alden. “But I won’t let him drop off. It’s been a helluva road, but I’m very proud of him and all the other soldiers along with him.”