It's hard to imagine Mualia Salamo in an argument. He has a soft voice that sounds almost musical, recalling the rustling palm fronds and lapping waves of his native Samoa. He smiles readily, even while ticking off the crashes and explosions that rattled his head during 21 years of U.S. Army service in Iraq, Korea and elsewhere.
Yet after Salamo arrived home last year, following his most recent concussion, a less peaceful side came out. He says his temper would flare even during simple discussions with his wife about paying bills or making plans.
"I would tell her, "Did you do this?'" he says. "And all of a sudden, I would just snap."
Salamo says anger management classes and medication have helped him get his temper under control. But there are plenty of other daunting challenges for his body and his mind.
This Tuesday morning at Penrose Hospital, a Fort Carson official looks on as a speech pathologist coaches Salamo through matching games on a computer to work on his memory. She then asks him to distinguish between pairs of objects.
"What's the difference between a newspaper and a book? A guitar and a piano?"
Salamo gets some questions right; he strains visibly to answer others.
Later, standing between parallel bars much lower than those used by a gymnast, Salamo balances on a series of ramps, cushions and rubber nubs. He trembles with effort at each task, clenching the legs of his athletic shorts to keep from grabbing the rails.
When his shaking suddenly stops, Krista Bohlen, a physical therapist, grows suspicious.
"Are you cheating?" she asks in a teasing voice.
Salamo bursts out laughing.
Salamo's gentle nature will likely serve the 44-year-old well as he struggles to adjust to life as a civilian. He left Iraq last year after a final injury left him wobbling and struggling to think straight.
The "signature wound'
The work ahead for Salamo and fellow soldiers with traumatic brain injuries, or TBIs, will be enormous, as will be the strain on the families and communities that will care for them. According to research published earlier this year, about 320,000 U.S. troops have suffered mild to severe brain injuries fighting in Iraq and Afghanistan since October 2001.
TBI-related treatment costs the Army up to $910 million per year and that's for just the tiny fraction of these soldiers who actually pursue and receive medical care. Though screening for brain injuries became standard for returning soldiers at Fort Carson in 2005, many slipped through the cracks before then.
Some argue that today's injured soldiers need more help. Presumptive Democratic presidential nominee Sen. Barack Obama and nine other senators wrote to Defense Secretary Robert Gates this week, asking him to increase medical coverage for brain-injured veterans coming home from Iraq. They call traumatic brain injuries the "signature wound of the conflicts in Iraq and Afghanistan" and argue that cognitive rehabilitation therapy like Salamo's work with the speech pathologist should be covered by TRICARE, the military's health insurance.
Tricare spokesman Austin Camacho counters that it is covered, as long as it's combined with other types of rehab.
Col. Heidi Terrio, a physician and chief of deployment health at Fort Carson's Evans Army Community Hospital, says she cannot yet give an exact number of brain injuries suffered by the 25,000 soldiers who have been screened in the past three years; the number will appear in an upcoming study. Though deployment lengths have varied, she suggests the injury is found in around 18 percent of soldiers deployed for a year.
Most of the soldiers who stick it out with their units have what's considered a mild brain injury; between 67 and 93 percent return to normal within three months, Terrio says.
"The brain is a remarkable thing," Terrio says. "It recovers well."
When it doesn't, though, soldiers can have family problems or become violent, homeless or dependent on drugs or alcohol.
Amber Nicodemus, whose husband came back from Iraq in 2006 with a brain injury so severe he could barely walk, speak or read, is starting the Cognogenesis BRRAIN Center to help the injured soldiers and their families.
Though many soldiers have brain injuries that are officially classified as mild, she says, repeated exposure to blasts can leave them with far worse impairment.
Caring for these wounded soldiers and managing a dozen or more weekly medical appointments can become almost a full-time job for spouses and other family members, Nicodemus says. Some have to cut back on work, creating a financial strain. Meanwhile, children struggle to understand changes to an injured parent.
"It's not just the soldier that has to recover," she says. "There are a lot of stresses that trickle down to the family."
The PTSD factor
Salamo is not expecting a full recovery. Despite his apparent cheerfulness, he sounds morbid when talking about the future.
"Most of the time, I feel helpless," he says. "My mind keeps going everywhere."
Crashes during training exercises in the '90s first hurt Salamo's head and made him dizzy. He managed for years, until being back in Iraq. Last June, he was knocked cold in a helicopter crash. When he went back to his unit, he felt he "wasn't really the same."
Two months later, he was trying to help unload an air conditioning unit from a truck when a mortar exploded nearby. The man above lost his grip, and the unit careened off Salamo's head and shoulder, giving him another concussion and ripping his bicep loose from its moorings. The muscle now curls into a tight ball when he flexes.
Salamo was sent home and joined Fort Carson's Warrior Transition Unit, which helps soldiers prepare for life outside the military. His separation date from the Army, originally set for the fall, was pushed back to next year while his treatment continues. He reached the rank of first sergeant in what will end up being a 22-year career.
He doesn't have specific plans about what he will do next: "I just want to go home and relax."
He laughs as he explains that he also wants to keep an eye on his daughters, 18 and 19, as they go through college. But they, and his wife, will probably have to keep an eye on him, too. He repeats himself, forgets things and gets frustrated easily, and his temper flares, causing arguments.
"It's hurting my family," he says.
Salamo, like many soldiers, has been diagnosed with PTSD, too. TBI and PTSD symptoms can overlap, with both often causing headaches, irritability and problems with sleeping.
Physically, though Salamo maintains the muscular build of a soldier, he sways when he walks and often stumbles. Though he could have permanent damage to the network of canals in the inner ear that clues the body which way is up, Bohlen, the physical therapist, says the goal in therapy is to help him strengthen other senses so he can compensate.
"Basically, it's to decrease the fall risk so he's functional," she says.
Salamo talks about trying in the past to ignore his injuries so he could stay with his unit, never wanting to stay behind. His injuries now loom too large.
"I hate to leave the Army, but it's time," he says.
CIRCLE of life
Military acronyms, titles and bureaucracy can be daunting. Kristi Ecklund, a Penrose Hospital neuro-physical therapist, says she's just starting to learn her way around.
"It's hard as a non-military person," she explains.
Ecklund is part of a group that brings together health care and service providers from the military and the community to find ways of helping soldiers deal with brain injuries.
It's called the CIRCLE Network, which stands for Colorado Information, Resource Coordination, Linkage and Education. Several of the groups meet in different parts of the state, with the group in Colorado Springs devoted to military brain injuries.
The groups are funded with a federal grant overseen by Sandy McCarthy, director of Colorado's TBI program at the state Department of Human Services. And they're coordinated by the nonprofit Brain Injury Association of Colorado (see "A challenge worth taking").
Ecklund says CIRCLE has helped its members figure out who to call when a soldier has issues with treatment or finding services. For instance, to help plan their days and remember appointments, many soldiers with TBIs are issued personal digital assistants, or PDAs. Pre-CIRCLE, it might have taken Ecklund a handful of telephone calls before she found the person who could find and set up a PDA for one of her patients; today, she knows to call a certain nurse at Fort Carson's Soldier Readiness Center.
A year ago, soldiers were rarely seen at Penrose for outpatient rehab. Now, Ecklund says, a new patient shows up every day.
Jaclyn Foust, a speech-language pathologist who works with Salamo, says 60 percent of the patients she sees are now soldiers. She says she's seen soldiers who could barely talk put their lives back together, and she speaks passionately about helping service members, explaining that her own son, a pilot in the Marines, just returned from Iraq.
"We're able here to help turn these soldiers around," Foust says.
There are local success stories; Nicodemus worked to get her husband into a 10-month cognitive rehab program last year, and she credits the training for teaching him to read and do math again.
Annie Alexander, who holds a doctorate in clinical psychology, works with each of the CIRCLE groups as the Brain Injury Association's TBI network coordinator. In Colorado Springs, she explains, discussions about coverage issues sometimes pop up, with some community providers believing more services and treatments should be provided. There's also talk about all that hinges on a soldier's discharge rating, which determines how much financial support the Army will make available, she says.
A fact sheet from the Department of Veterans Affairs lists disability payments soldiers receive. At 10 percent disability, the most common level, the monthly payment is $117. Compensation climbs to $356 for 30 percent disability, and soldiers rated that level or above can get an additional allowance for their spouse or children.
Soldiers with one disability rated 60 percent or higher can qualify for an "individual unemployability" benefit, meaning they receive 100 percent disability payments of $2,527 a month.
Less is ... less
Moderate and severe brain injuries can be obvious: When a soldier is knocked unconscious by a massive blow to the head or a bomb blast, there might be bleeding or an X-ray showing a skull fracture. Mild brain injuries are more subtle, sometimes caused by a bump to the head or, commonly, by the sound waves from an explosive blast.
The soldier might feel confused for an instant, or even lose consciousness. But even stricken with headaches and sleepless nights afterward, he will have nothing to point to to indicate an injury.
Damage to the brain is still real, according to Ronald Ruff, a neuropsychologist who has treated and studied TBIs for 30 years. He talks about research on monkeys that were shaken up much as soldiers can be by bomb blasts. When the monkeys' brains were cut open and examined, Ruff says, researchers found real physical loss of brain cells.
People start off with billions of brain cells and might be able to afford losing a few million. But Ruff says the cumulative effects of multiple injuries can be significant.
"The more you lose, the worse off you are," he says.
Losing brain cells is natural as people age, and having extra cells can be a luxury for younger soldiers. Ruff estimates 80 percent of people with TBIs make a "pretty good recovery." He terms those who do not the "miserable minority."
Brain injuries were also common during the Vietnam war, but the focus then was on severe head injuries. Understanding about mild brain injuries has increased since then, but Ruff seems puzzled that anyone is surprised about what we are seeing.
"This is what we expect in a war," he says. He adds, "They have lost the expected future."
Unfortunately, the tendency is to stop giving treatment when they stop improving. Ruff says communities need to find ways of helping patients with brain injuries come up with new goals and build motivation to achieve them.
Back at Fort Carson, new procedures to screen for brain injuries are being adopted. Soldiers about to be deployed last month were evaluated using the Automated Neuropsychological Assessment Metrics, or ANAM, for the first time. This series of tests measures how the brain is functioning and is meant to give a value for comparison when the soldier returns.
Meanwhile, the Defense and Veterans Brain Injury Center is updating a protocol it developed in 2006 for identifying returning soldiers with brain injuries, says James Kelly, chair of a Pentagon subcommittee on TBIs and professor of neurosurgery at the University of Colorado Denver. The revised protocol will be aimed at seeing the injury is diagnosed earlier and that soldiers get treatment earlier. As McCarthy notes, that will help them avoid the feelings of helplessness that can lead to family disruptions, aggressive behavior and even prison.
Even so, communities across the country are still going to face challenges.
"What we need to do," Kelly says, "is get the civilian sector prepared for this."
A trio of local organizations trying to help wounded soldiers and their families:
Cognogenesis BRRAIN (Brain-Injury Resource, Research Advocacy & Integration Network) Center
1259 Lake Plaza Drive, #130, Colorado Springs, CO 80906, 271-9627
A new center to provide wide-ranging services, care, support, job training and other assistance to brain-injured soldiers and their families. Started by Amber Nicodemus, whose husband suffered brain injuries from being close to repeated blasts in Iraq.
Home Front Cares
P.O. Box 38516, Colorado Springs, CO 80937, 447-3838, thehomefrontcares.org
Funds programs to help families visit wounded military personnel, provides support to those families, and also has an energy assistance fund to help military families in need.
3595 E. Fountain Blvd., Suite F2, Colorado Springs, CO 80910, thankstroopsgolf.com
Provides activities and athletic equipment to help wounded soldiers and their families.