The bomb, two large artillery shells buried at the side of the road, exploded just a few feet in front of the Stryker.
The blast in central Iraq didn’t so much as puncture the tires. But it hit the soldiers inside so hard that some couldn’t think straight for days.
“The first few days were miserable. I was wearing sunglasses inside my room. … My head was just pounding,” said Sgt. Brian Kerrigan, who was seated at the gunner’s station.
Luckily, none of the football-sized chunks of asphalt thrown by the bomb hit Command Sgt. Maj. Jeffrey Du, who was standing in a hatch with his head and shoulders exposed. But the pressure wave rocked him hard enough to give him a severe concussion.
Ten days later: Same Stryker vehicle, another patrol, another explosion, more injuries.
Two months later: Both men are still feeling the effects.
Kerrigan and Du are among hundreds of soldiers from the 3rd Brigade, 2nd Infantry Division, just now back from 15 months in Iraq, who are dealing with what has been called the signature injury of the Iraq war.
It’s referred to as mild traumatic brain injury, or mTBI, to distinguish it from more severe cases in which patients must relearn to walk or talk, or worse.
But there’s nothing mild about the way these injuries are inflicted. And the symptoms can profoundly change the lives of soldiers.
They can have persistent headaches, feel restless and tired, be easily frustrated and irritable, and have trouble remembering things or doing more than one task at a time. All can lead to trouble at work and home, especially when symptoms are compounded by the anxiety, depression and other mental health issues that many soldiers bring home from combat.
Post-traumatic stress disorder and mTBI share some symptoms, but there are differences. Patients with brain injuries alone do not typically suffer nightmares and flashbacks, for example.
“When the brain is injured, the behavior is going to change. Emotions don’t appear out of the air,” said Kenneth Zych, a Madigan Army Medical Center neuropsychologist who treats returning soldiers. “The brain is the organ of behavior, and when that organ is injured, you will have results.”
New screenings for returning Stryker troops and creation of a TBI center at Madigan are among the ways the Army is confronting the challenge of brain injuries.
But Army medical officials acknowledge that their service was slow to recognize and respond to the growing numbers of soldiers at risk for mTBI as insurgent bombs struck with greater power and frequency across Iraq.
Research into the civilian form of mTBI generally caused by concussions shows that most people will fully recover over time with rest and by avoiding additional concussions.
But experts arent sure that injuries caused by blasts heal the same way. While much is known about the way the brain reacts to concussions caused by car accidents or sports injuries, researchers are only beginning to examine its response to explosions.
Recent studies suggest that blasts might slowly kill brain cells over months and years, leading to permanent loss of function. Those whose symptoms dont go away, and the people close to them, have to learn to live with the condition.
After the August explosion, Du, 50, lost his appetite and had trouble sleeping problems that persist today.
Kerrigan, 29, says hes conscious of changes in himself. At his home in Frederickson, hes caught himself staring blankly at the TV during a Seattle Seahawks game, or getting unusually aggravated when his kids Cian, 6, and Abbey Rose, 5 leave their toys around or make a racket.
Kerrigan is also recovering from wounds he suffered in the second explosion, including a shrapnel gash in his right forearm. He said hes uncertain how it will all work out.
I can see my arm and know that its healing. But I cant see my brain, he said. I think that theres a lot of soldiers who are going to have issues with this later, and its going to be one of those things where a lot of people are going to push it off Hes just faking it, its not that bad, you know.
I really pray and hope people arent like that, but some of these guys, maybe myself included, are going to come into some of these roadblocks in life.
Blast concussions have been a fact of life for soldiers in Iraq since late 2003, the first year of the war. Due to protective gear and advances in battlefield medicine, soldiers are surviving wounds that in past wars would have killed them.
But only this year did the Army launch specific programs to identify potential mTBI sufferers and to teach soldiers, leaders and family members to recognize signs of the injury.
Dr. Frederick Flynn, a longtime neurologist at Madigan and medical director of the new TBI center, notes that the Army has been dealing with soldiers with TBI for a long time primarily those who suffer moderate to severe cases.
Anyone would say in hindsight that we could have done better in responding to the growing numbers, Flynn said. But we are screening every single soldier who comes back for this specific problem.
The new programs are part of the Army Medical Action Plan, which arose after media reports of problems at Walter Reed Army Medical Center in Washington, D.C.
Combat medics early this year received new guidance for how to assess and treat soldiers who might have concussions.
At Fort Lewis, soldiers returning from Iraq and Afghanistan are now required to complete an online questionnaire designed to find those at risk for mTBI.
The 3rd Brigade is the first major unit at Lewis to go through it. Through the end of October, 2,325 of the brigades 3,800 soldiers have done so. Of those, 1,000 were found to have likely suffered an mTBI and were recommended for secondary screening at Madigan, which consists of further tests of their cognitive abilities and an appointment to talk with a senior physician or a psychologist.
Of those 1,000, so far 205 soldiers have been referred to further treatment because they continue to suffer signs and symptoms. The figures include some of the 204 soldiers who were diagnosed with mTBIs while the brigade was in Iraq, brigade officials said.
Flynn said all 3,800 soldiers in the brigade will be screened again in three to six months.
The military is still trying to get a grasp on the scale of the injury. Since the beginning of 2003, the Defense and Veterans Brain Injury Center has seen nearly 4,500 TBI patients at 11 treatment sites around the country and one in Germany. But that figure doesnt include patients seen at other locations, including Madigan, or the thousands of service members seen by doctors in Iraq and returned to duty.
Medical officials estimate between 10 and 20 percent of all service members deployed to Iraq had a mild TBI at some point, said Chuck Dasey, a spokesman at Walter Reed Army Medical Center.
With 160,000 now deployed in Iraq, that would be between 1,600 and 3,200 troops.
Madigan and Fort Lewis have received $1.3 million from the last Iraq war supplemental spending bill to create a TBI center, and are hiring a staff of about two dozen neurologists, psychologists, therapists and others to work there. Congress also provided money for similar centers at most major Army posts.
The Government Accountability Office in September said the Pentagon and the VA still face several hurdles to improve care for wounded soldiers, including those with mTBI, in particular finding staff to work on the new initiatives.
At Madigan, officials acknowledge the prospect of being overwhelmed with new patients from the war zones. They say they have had to move providers within Madigan to respond to the surge of returning 3rd Brigade soldiers.
Their guiding principle, they say, is to prevent soldiers and families from the bad effects of unrecognized brain injury, and to reassure them. They also teach coping skills, whether that means learning new habits to cover for haphazard memory or taking on a new job that doesnt require tracking many tasks at once.
We want to leave them with the natural sense that they are going to get better, they are going to improve, that we have treatment, we have follow-up, Flynn said. Were not going to abandon them, and that there are ample opportunities for them to seek us out as well if they continue to have any problems.
A STEP FORWARD
U.S. Sen. Patty Murray, a leading critic of the treatment of returning Iraq and Afghanistan veterans, said she applauds the new programs at Fort Lewis and Madigan.
Its a step forward that we certainly didnt have even a year ago, she said.
But she and others question whether the Defense Department and the VA will follow through, noting the agencies track records of inadequate staffing, long waits and confounding bureaucracy.
Madigan is doing something today that they wouldnt have without the sound and fury from Walter Reed, the Washington Democrat said. But to me the measure of success is three, five, seven years from now and we dont hear about people who went home and were suffering because they werent identified and treated.
Patrick Campbell said the military is playing catch-up in its response to mTBI. The former Iraq combat medic is now legislative director with the Iraq and Afghanistan Veterans of America.
He said the Army should have mandatory predeployment screenings for soldiers headed to Iraq.
Screens are a tool, said Campbell, who went to Iraq with a Louisiana National Guard infantry brigade in 2004-05. Theyre widely implemented, but the follow-up is severely lacking. Commanders are being evaluated on how many are taking the survey, but the next step of accountability is how many people are getting into care.
Soldiers also need to remember that they should document their exposure to blasts when theyre deployed so they have evidence to support their claims for benefits back home, he said.
A major question remains what will be done to reach back to the service members who came and went before the new emphasis on mTBI. Campbell says he hears from them all the time, with problems such as Why am I going through weeks of depression at a time? Why cant I keep a job? and My wife is going to leave me if I dont fix things soon.
I was the medic so Im the guy they call, he said.
Its never too late to go back and start screening those people, Campbell said. If we dont have a coordinated effort on this, then people are just going to keep falling through the cracks.
I FORCED HIM
One of the cardinal rules in dealing with concussions is making sure a person doesnt get another one before the first has had time to heal. Its why high school athletic associations have stringent restrictions against players coming back too soon from head injuries.
But on the streets and the highways of Iraq, there were plenty of opportunities for 3rd Brigade soldiers to get blown up more than once.
And they generally were reluctant to stand down for long after theyd been hit.
You had to order guys, said Lt. Col. Barry Huggins, who commanded the brigades 2nd Battalion, 3rd Infantry Regiment.
In action from Mosul to Baghdad to Najaf, he estimated his battalion of some 770 soldiers and 317 Stryker vehicles got hit, on average, at least a dozen times a month with roadside bombs.
For the most part guys had to be told You will stand down. You will not go off the FOB (forward operating base), he said. They did not want to be seen as shirking.
The brigades surgeon, Lt. Col. Michael Oshiki, estimates doctors wrote hundreds of one-day to three-day profiles for 3rd Brigade soldiers orders preventing them from going back out on patrol after theyd had their bell rung in an explosion. By early 2007 about halfway through their deployment new procedures went into place requiring soldiers involved in explosions to be evaluated by medics on their return to the operating base, he said.
Command Sgt. Maj. Du didnt believe he could sit still for long after he was bombed with Kerrigan in late August. Du, the top enlisted leader in the brigade, is responsible for the welfare of some 3,800 soldiers.
The doctor was kind of wary if I should go out or not, Du said. But they retested me and I told him I forced him I said, Hey, I really dont want them to go out without me.
I need to be out there with the boys, thats what I told him. He said I was well enough to go out as far as he could see, but he was kind of worried that wed get hit again and Id get a concussion.
Oshiki recalled his advice to Du.
Hell tell you that he should have listened to me when I said dont go back out, the surgeon said.
He took a hit. His brain was still inflamed after the hit he took coming back from Baqouba. Hell tell you straight up. Hes told me half a dozen times since coming back, Doc, I should have listened to you.
Du said he hasnt done his post-deployment mTBI screening or visited the Madigan neuropsychologists yet, but said he will.
A PRETTY BIG HIT
Maj. Brett Clemmer, who was a company commander for the first half of the deployment, figures he ate, as he put it, at least three enemy bombs.
The adrenaline gets pumping. Youre a leader and youre going, Are you OK? Am I OK? Are all my people OK? Yes? Then lets find this guy who just tried to kill us, and kill him, Clemmer said.
Now a veteran of three combat tours one in Afghanistan and two in Iraq Clemmer managed to avoid serious injury during the just-ended deployment.
And he wouldnt let a head injury keep him down until he literally fell to the ground.
One day in Mosul, a suicide car bomber hit the Stryker right behind him in their three-vehicle convoy. The explosion was devastating.
It threw me forward and down into the hatch, Clemmer said.
His driver kept moving, but by the time Clemmer picked himself up and looked back, they could see no one was following. So they turned around and went back, where the Stryker that had been bombed was on fire.
As Clemmers men were pulling out the injured, insurgents opened up with rocket-propelled grenades and small-arms fire. The soldiers loaded the wounded onto the two other Strykers and raced them to the hospital.
Thats when Clemmers adrenaline ran out. Oshiki, the brigade surgeon, was a witness.
I saw these guys when they got back to the (hospital) and this commander had been pushing, pushing, pushing, Oshiki recalled. Hed taken a pretty big hit.
He got his guys back all right, then literally dropped to the floor. We ended up hospitalizing him. He got a significant TBI from that but slogged through it.
Clemmer said he had an MRI and spent the night in the hospital, but he was back to his company by 7 the next morning. He went out on patrol later that day.
If it were one of his guys that had experienced that in the field, Oshiki said, he probably would have made that guy get medevacd. But because he was the commander he felt he had to stay there.
Not surprisingly, Clemmer was targeted for further assessment at Madigan shortly after his return home in September.
He easily qualified for a visit with the neuropsychologist. It included some further cognitive tests, and then a chance to talk one-on-one, behind closed doors, about his experiences in Iraq.
Fifteen months is a long time, and I got blown up a lot, Clemmer said. It was nice to come back, it wasnt group therapy, just you and another guy with the door closed, and you talk about it and take the tests and get immediate feedback.
In the weeks before their return from Iraq, Clemmer said brigade leaders stressed from the top down that everyone should answer the questionnaires candidly and that there would be no stigma attached to anyone who sought help.
You never read about the guy who comes home and hes just fine. You read about the guy who comes home and has problems with his wife, and you dont want to be that guy, Clemmer said.
Theres a lot of stuff I worry about. You hear of guys who cant remember their bank PIN or their family members names, or you forget to do what you told your wife, pay a bill, pick up something on the way home, Clemmer said. It spirals into frustration, and you think, Somethings wrong with me.
Thats what I worry about. It hasnt happened to me, but thats probably a big concern for a lot of people.
Clemmer, 34, said he was impressed by the program he found at Madigan.
It helped me a lot,: he said. It was reassuring to me that we are doing something different this time.
Its too early to tell the extent to which 3rd Brigade soldiers will suffer from mTBI. Many are still in that phase where they see any problem here as minor compared to the life-and-death experiences of Iraq.
But Fort Lewis officials say they know the honeymoon feeling can wear off. Thats why they have another extensive mental health screening and assessment program required for soldiers after theyre home three to six months.
At the Kerrigans home in Frederickson, theyre focused on his recovery from wounds to his arm, legs and abdomen. Hes doing physical and occupational therapy at Madigan, and recently returned to work at the brigade headquarters.
He keeps two pieces of shrapnel that surgeons removed from him in a little plastic container on the mantel.
Kerrigan is beginning to talk to doctors about his head injury. He said he wont try to tough that one out; if he thinks he needs help, hell ask.
Worry about the possible long-term effects of his head injury will wait, but Andrea Kerrigan said she wants to be optimistic.
Theres physical wounds, and theres mental wounds, she said. He struggles going to sleep, he struggles being alone. Thats difficult because you try to be strong and understand, but its hard.
I think we can do this and we can move forward.
Kerrigan plans to finish his enlistment next spring and then leave the Army for school. He had planned on pursuing a job with a local police department but that hinges now on whether he regains full strength in his arm.
He expects hell become active in veterans affairs. He has mixed feelings about going through the system to seek benefits.
I dont want to take money from the VA if Im OK, but then I think, Wait a minute, thats what the money is for, he said.
What if 20 years from now I start having headaches again, or start losing my memory, or what if my arm hurts? You want to be sure to cover yourself for you and your family. But at the same time there is a mentality of a soldier: Tough up, heal up and handle it and get back out there, drive on.
He said hes taken the initiative to learn about the potential impacts of mTBI. He counseled a friend who was exposed to blasts just like him but was never diagnosed with a concussion.
It really is up to the soldier to go out and say, I need help, because the Army is not going to ask you if you need help, Kerrigan said. You have to look out for yourself and ask.