Mission Critical

Michael Sugrue

CPL. Jason Poole was 17 when he joined the U.S. Marine Corps in 2000. On his third tour of duty in Iraq in 2004, Poole was in a group patrolling near the Syrian border when an improvised explosive device (IED) detonated, killing two Marines and an interpreter, and ripping the top left part of Poole's head off.

Unconscious, Poole was airlifted to a medical facility in Iraq and quickly transferred to a military hospital in Landstuhl, Germany, then to the National Naval Medical Center in Bethesda, Md. He had surgery to repair and seal his skull and remained in a coma for almost two more months. When he finally awoke to see the excited face of his twin sister, Poole says he was frightened and disoriented—although he laughs at the memory of reaching immediately for his head. "I thought I'd have some big Afro after two months, but my head was shaved."

Five years after that horrific blast, he sits in a visitors' lounge at the Veterans Affairs Palo Alto Health Care System. He is blind in his left eye, deaf in his left ear. His right side is weak and his right arm heavily scarred. His hands and arms still contain scores of faint, freckle-sized black specks of shrapnel. But many subsequent surgeries have given Jason back a friendly and good-looking face whose scars do not overshadow his easy, bright smile. That, in itself, is something of a miracle. Not to mention the fact that he has relearned how to speak, how to eat, how to read, how to walk.

There is no official definition for polytrauma in most dictionaries, although it's easy enough to figure out. "Trauma" is bodily shock or emotional injury. "Poly" is from the ancient Greek for "many."

But at the VA Palo Alto's Ward 7D, the Polytrauma Rehabilitation Center, the idea of "many" shocks and injuries barely does reality justice. For the past several years, a special group of mostly young patients here at once embodies the achingly tragic consequences of modern armed conflict and its unprecedented medical challenges. It falls on the shoulders of program director Sandy Lai to quarterback a large team of caregivers who are on the front lines of rebuilding the physical, emotional and functional lives of service members with some of the most complex injuries ever to emerge from war.

Only a few years ago, Lai, '93, was treating a population that might seem very different. She was an associate physician at UCLA's Arthur Ashe Student Health and Wellness Center, where she encountered the typical array of student health concerns ranging from pinkeye and sprained ankles to anorexia and depression. But Lai was drawn to the idea of designing a comprehensive health-care system for young adults that emphasized prevention and wellness, and understanding the social and family components that affect that. She earned an MBA at UCLA to fine-tune her management and program development skills.

In 2006, Lai's husband, Joseph Liao, MD '97 (they met as residents at UCLA), was hired as chief of urology at the VA Palo Alto and an assistant professor at Stanford, and the couple moved north with their two young children. When the assistant medical director job came open at the Polytrauma Rehabilitation Center, Lai's interest and skills dovetailed with the VA's need for a new kind of medical team leader.

"We wanted to build a team that addressed the special needs of this population," explains Stephen Ezeji-Okoye, a physician who serves as deputy chief of staff of the VA Palo Alto. "Dr. Lai had two big strengths—she had been interacting with patients of the same age as the ones we are serving, and she had an MBA and so understood program management and problem solving."

Indeed, the VA system was in the midst of rethinking its care of polytrauma patients, and Lai, who was promoted to program director of the PRC in 2007, has played an important role in that transition. Palo Alto is one of four specially designed centers, along with those in Minneapolis, Tampa, Fla., and Richmond, Va., that were chartered in 2005 to address what the U.S. military acknowledges is a signature injury of its operations in Afghanistan and Iraq: traumatic brain injury (TBI) in combination with other combat wounds. Service members patrolling debris-strewn streets and crowded areas are vulnerable to booby-trapped roadside bombs that not only hurl shrapnel into and through body tissue at tremendous force and create burns, but also produce a shock wave that can severely damage the brain without any visible sign of injury. In March 2009, Pentagon officials reported that more than 350,000 service members returned from deployment in Iraq and Afghanistan may have suffered some form of brain injury. (This includes mild TBI, also known as concussion.) The Department of Veterans Affairs estimates it has treated 8,000 brain injuries in this population. So far about 700 of the most gravely injured have been treated in the four PRCs, almost 200 in Palo Alto.

Two aspects of the deployments in Afghanistan and Iraq have created new and challenging dimensions for the care of the patients in 7D. First, it is somewhat miraculous that they are alive at all. In past conflicts, certainly World War II but even Vietnam, "people with this level of injury would have died," explains Ezeji-Okoye. Today, new field procedures and technologies can stanch bleeding in the field and get a wounded service member to a military transport jet capable of providing advanced surgeries in midair in a matter of hours. When the patients emerge from a minimally conscious state, however, they often confront profound physical disfigurements, missing limbs and serious organ damage. That's difficult enough. But their TBIs also produce myriad neurological symptoms, which can include amnesia, headaches, dizziness, vision problems, and the inability to concentrate, swallow, speak or read. They also suffer from insomnia and nightmares. And they battle other common symptoms of post-traumatic stress disorder, such as a lack of impulse control, flashbacks and irritability. Together, these issues impact their ability to think, to sleep, to see, to interact normally with others—even to recognize their spouses and children.

Jason Poole's sunny demeanor masks the lingering consequences of his brain injury. He has no memory of the explosion that changed his life. He has trouble finding the right words sometimes, and it's hard to concentrate when he reads. As we talk, another patient at the Palo Alto VA Hospital with a traumatic brain injury, a slight, pale young man who has been standing a bit uncomfortably near us, suddenly pulls up a chair and announces, "I find when I join a group, the group stops functioning as it has been."

Such jarring comments are not uncommon here. TBI robs many patients of the ability to empathize, read social situations or interact as expected. Jason's compassion and social skills are intact. In fact, he leans toward the anxious young man with genuine concern and reassures him that we're simply in the middle of a conversation we need to finish. No hard feelings, nothing to worry about. In fact, "I'll catch up with you later, man."

The second aspect of these patients' lives that demands a new approach is their youth. Before the war, [the VA facilities] mostly were dealing with the Vietnam veteran population, which is much older," Lai explains. The Afghanistan and Iraq service members "do not want to play bingo as rehabilitation. They have more energy, they are more technology oriented. They even have bigger appetites. We have redesigned the kitchens so they and their families can access food more easily; we have brought in Wii systems and personal computers for their recreational therapy." Also notable: Because of their youth, these veterans have families that are far more involved in their care than many older veterans, and those families have expectations for the patients' recovery that the staff have to both support and manage. "We always try to focus on the possibilities," Lai says. "When we admit the patient, he or she may have a serious disfigurement. We try to focus on what we know is possible, that a prosthetic, for example, will eventually restore a normal-looking head to the patient, and that young people's ability to heal is quite amazing."

Lai was instrumental in developing the four PRCs' "family-centered care" philosophy, which from day one strikes a partnership with the injured service members' families, including parents and often very young spouses who are overwhelmed by the tragedy. She explains: "The family has to go through a process; in the beginning they want to be by the patient's bedside 24/7. They don't want to shower, don't want to eat. We gradually help them take baby steps to understand that to best support their family member, they must take care of themselves."

Patients spend an average of 42 days in Ward 7D. Coma patients spend at least 90 days, most at least six months. During that time, an extraordinary number of specialists work with them. When Lai settles into a chair at her team's biweekly meeting to discuss cases, she joins about 20 different team members from physiatry, rehabilitation nursing, blind rehabilitation nursing, neuropsychology, psychology, speech-language pathology, occupational therapy, physical therapy, social work, chaplaincy, nutrition, therapeutic recreation and prosthetics. Virtually every one has an opinion and a therapeutic or diagnostic angle on the patients under discussion. They comment on everything from the growing strength in one patient's injured leg to how to convince another patient to take his medications. All are encouraged to contribute any insight or observation that may help. A speech pathology aide, for example, shares that she discovered that one of the patients is particularly interested in basketball. These are the seemingly small but significant in-sights that can provide a window on motivating a patient in a new way.

They talk about strategies for working with patients' family members—sometimes mothers bring in foods that are inappropriate for a patient, for example. They also discuss plans to gradually shift some of the 7D patients into the next recovery phase. Although most patients will be discharged to go home with families, some will transition to another inpatient program. Those patients will still be monitored but allowed more freedom and given therapy designed to make them more independent eventually, such as practice on driving simulators for those capable of someday operating a car again. Most will nevertheless need some kind of outpatient support where they live for the foreseeable future.

If he looks straight at me, Jason Poole explains, he can see and recognize my face distinctly. His right eye itself was not damaged in the blast and has been assessed as having 20/20 acuity. However, he demonstrates that if he turns his head to the left and stretches his eye to the right—well, he struggles to find the right words to explain what happens, eventually settling on, "Now you're an image but not a face." He can see me still, but at this angle his brain cannot properly process the image.

The PRC's team-based approach is yielding new insights that help the patients' entire rehabilitative experience. For example, Lai's colleagues have shown how blasts can harm a patient's vision even when a wound is not apparent—in fact, Palo Alto's TBI vision team has been awarded the VA system's 2009 Olin Teague Award for research teams involved with war-related injuries. "Over 50 percent of the brain is connected directly or indirectly into the visual system. Any significant trauma has a relatively high probability of affecting vision or visual information processing," explains Gregory L. Goodrich, supervisory research psychologist and coordinator of the optometry research fellowship program. Yet, adds Glenn Cockerham, chief of the ophthalmology section and a clinical associate professor of ophthalmology and pathology at Stanford, "These ocular injuries are silent. The patients don't know they have it, they have no symptoms and their acuity can be 20/20." An early study of 125 patients with mild traumatic brain injury showed that only about 2 percent of the group had visual impairment (meaning acuity, or ability to see) but as many as 40 percent had some kind of visual dysfunction, such as double vision or trouble tracking moving objects. In the polytrauma population, adds Goodrich, more than one-third have significant acuity or visual field loss, which can interfere with rehabilitative therapies to restore reading comprehension or even to improve balance in physical therapy. Now, with more comprehensive screening, doctors are finding vision problems—often treatable—early, and that helps the patients' progress across the board. "We've been extraordinarily lucky here with an administrative group that was willing to understand what we are trying to do, and to make us part of the team. We can trade information back and forth," Goodrich says.

More broadly, all service members are being screened and followed more intensely after blast exposures or after discharge, and the military is encouraging them to seek treatment for TBI as early as possible to maximize their recovery. Lai acknowledges that service members with mild TBI sometimes are reluctant to seek help, especially when they have no visible physical injuries. In the early phases of the current conflict, she says, "What would happen is that people wanted to go home as quickly as possible so they weren't always honest on their discharge form about their symptoms. They didn't want to put down that they were having headaches, sleeplessness, memory problems, hypervigilance—if you take each individual symptom it may not seem so severe, but together they actually warrant aggressive intervention. In combination, these symptoms can be very disruptive to the patient's life."

At rounds one day, the attending physician and two residents discuss several issues confronting a 24-year-old man recovering from blast injuries in Iraq. "He's angry. At us, at the service, at everybody," sighs the nurse. He is suffering intense leg pain, and he is not complying with his physical therapy regimen. They move on to a trickier issue: sleep hygiene, or the quantity and quality of a patient's much-needed rest. It seems the patient's wife tends to visit him in the evenings and stay sometimes until one or two in the morning, watching movies, listening to music. Because the patient stays up so late he is groggy until late in the morning, missing prime physical therapy hours. They agree that a social worker needs to get involved to help convey the importance of rest to the patient and his wife.

Lai's specialty, family medicine, helps her pursue a holistic approach to the care of these patients. She is from a medical family in New Jersey—her father is an anesthesiologist; her mother was a nurse; her sister is an orthopedic spine surgeon—and is the only family medicine specialist directing a PRC (most other administrators are specialists in rehabilitative medicine). Lai believes her training helps her make sure these young patients are understood in the context of their age and appreciated as members of a larger social system that contributes to their care and recovery. "In the Vietnam era, we saw veterans who became isolated, who came to believe they could not succeed, and they would turn to substance abuse," she explains. Lai's team is focused on helping today's patients develop the skills they will need to be as independent as possible, but also to function in social groups, at work and with other people who share their interests. "We want to think more about how to prepare the patient, and also the caregivers, for the future."

Lai and her team need all the tools they can gather to meet such a complex challenge. Recreational therapists now routinely use tech gadgets like Wii consoles to help patients regain hand-eye coordination and other skills that these games, very likely a component of their pre-injury lives, can teach. A new program called "Paws for Purple Hearts" that is run out of the VA's Menlo Park campus brings dogs over to the Palo Alto campus. Working with animals can produce dramatic progress for many patients to whom animals were important before their injuries. "Some patients in an emerging consciousness state will follow a dog around the room with their eyes," even when they otherwise do not respond to humans, says Lai. In Menlo Park, meanwhile, patients learn to train dogs in the program. When those who have trouble sleeping are assigned a dog who sleeps in their room with them, they report sleeping much better and requiring less medication.

Even after five years, Jason Poole still sleeps only a few hours at a time. He would like to try working with a dog so that he does not have to rely on medications. Overall, however, his determination and efforts have resulted in remarkable progress. Three years ago, he met a young woman to whom he now is engaged. "Of course I get down sometimes," he says. "But after 10 minutes or so, I just choose to be positive."

Lai says the members of her team, often exposed to some of the most heartbreaking injuries and tragedies to confront a young family, have trained themselves to focus on the possibilities and the triumphs of patients like Jason Poole, rather than on what's been lost. She says it has taken time for her to follow her advice to families and make sure she's carving out restorative and quality time with her own family on her weekends and vacations.

The recent surge in military missions in Afghanistan is again increasing the number of new patients arriving in 7D, after a lull as the United States reduced its operations in Iraq. But in most cases the battles of patients who have come through 7D will go on, to some degree, forever. Sandy Lai and her team at the VA are determined to make sure these patients don't fight those battles alone.

JOAN O'C. HAMILTON, '83, is a frequent contributor to Stanford.