You may not see the damage, but traumatic brain injuries are leaving cruel marks on veterans from Iraq and Afghanistan. What can be done to help them recover?
He knew he held a dangerous job, running food, supplies, and ammunition to U.S. soldiers in Iraq. But Captain Anthony Lamar Smith hailed from a line of military men and loved the adventure and camaraderie of wartime. As an Army special operations quartermaster, he'd good-naturedly remind the infantry, "You can't shoot your guns without my bullets."
On the night of April 24, 2004, Smith was checking supplies in the materiel handling area of a camp north of Baghdad when the infantry came under attack. An Iranian insurgent launched a rocket propelled grenade (RPG) that struck Smith directly in the hip. It blasted through him, cracking his body armor, and blew up behind him, slamming him into a concrete wall. Reaching to pull a buddy toward him, Smith was hit again, this time by mortar that ripped off his lower right arm and decimated a kidney. The attack killed his comrade, whose body lay on top of Smith until rescuers finally found them.
From there, things went from bad to worse — and then to a little better. Ground medics pumped Smith with the wrong blood type. He flatlined, was listed killed in action, and tucked inside a body bag. He was still alive. The bag was partially open, or Smith would have suffocated. A nurse, in search of his toe tag, unzipped the bag. That's when Smith sat up. "I like to have cleared the room," he laughs now. The last thing he remembers is being loaded onto a helicopter, hearing someone yell, "Grab his arm!" and feeling the dismembered limb lying on his chest.
Transported to Walter Reed Army Medical Center in Washington, and later to Brooke Army Medical Center in San Antonio, Smith eventually underwent 106 surgeries. He lost a kidney and one-fourth of his large intestines. His bowels were resectioned and for two years he wore a colostomy bag. He suffered burns along the right side of his body, and his upper right arm bears a crater where the flesh was removed. His lower right arm is now fitted with a prosthetic. His right hip was replaced, causing his leg to be three inches shorter than the other leg. For elevation, he wears what he calls his "Frankenstein shoe."
But Smith sustained injuries to more than his torso. When he woke up from a three-month coma on July 12, 2004, he thought he was still in Iraq. He gradually reoriented himself, but his mind groped to figure out the simplest tasks. "I was basically back at first-grade level," says the 41-year-old, now an Army major. "I had to relearn a lot of things." In the meantime his wife took off with two of their children. "She didn't want to deal with what was happening to me," recalls Smith. His oldest daughter, two siblings, and a friend took turns staying with him at the hospital, until he went back to his home in Blytheville, Arkansas.
Now, more than four years later, the strapping, straight-up former dead man lives alone. A girlfriend and neighbor check on him often. He swims, kayaks, plays archery, and drives with the help of prosthetic attachments. He receives medical care and physical therapy at the Memphis Veterans Administration Medical Center.
But inside his head a battle wages to keep his life under control. His mind wanders. He posts notes all over his house to keep him on track. His eyes blur, his peripheral vision is gone, his ears ring constantly, and his right eardrum is ruined. If he overexerts, his head throbs with migraines. He likes to read but manages only small sections at a time. He smiles and his right eye nearly shuts. Smith was diagnosed with a severe traumatic brain injury (TBI), caused by shrapnel striking his temple and over his right eye.
TBIs aren't new. According to the Centers for Disease Control, 1.4 million Americans sustain such an injury each year; most are caused by falls, motor-vehicle crashes, or being struck in the head. However, wounded veterans returning from Iraq and Afghanistan are driving up that figure. According to a recent report from the nonprofit think-tank Rand Corp., 320,000 servicemen and women have some degree of TBI, prompting physicians and scientists to call it the signature injury of this five-and-a-half-year conflict.
Some soldiers, like Smith, incur TBI from a penetration of the head by shrapnel. But with many others, the skull isn't breached. Instead, soldiers are exposed repeatedly to blasts from roadside bombs or improvised explosive devices (IEDs) and often they get up and re-enter the fray. But the blast wave has damaged brain cells in ways researchers are just beginning to understand. Some compare it to shaken baby syndrome. One soldier described it as "getting your brain tossed around like an egg in a bucket of water."
"When the blast goes off, it rapidly expands at a phenomenal rate of speed," says Dr. John Whirley, staff psychologist at the Memphis VA. "This creates a compressed gaseous mass that's rolling and pushing through the air. It can injure the body and its organs in so many ways. With the brain, an injury anywhere can affect the entire function, especially the part that involves planning and organizing."
In the past, adds Whirley, soldiers often died from bodily injuries before the brain damage became apparent. Now, with improved armor and medical advances, more soldiers are surviving — but at what price? The Rand report puts the cost of TBI care alone at $600 to $900 million over the next two years; that amount, combined with treatment for veterans' depression and other mental health problems, will send the figure soaring to $6.2 billion. That doesn't include the toll such injuries can take on lives, livelihoods, and personal relationships.
Those with mild brain injuries gradually regain much of their brain function, though some will have permanent cognitive impairment. Still others won't experience symptoms for months or years after blast exposure. Those with severe brain injuries may never be the same.
Of the 4,000 veterans from Iraq and Afghanistan now being treated at the Memphis VA, about 400 have screened positive for TBI. All were stabilized or treated for injuries at Level I VA centers overseas or in the U.S. before being sent to Memphis' Level III facility at Jefferson and Pauline. The majority of these soldiers are young — between 20 and 30 — though some, like Smith, are past 40. Those we interviewed say the injury has changed their lives in ways they never foresaw. They appear to keep a positive outlook and do all they can to adjust. As they fight a different war on the homefront, their unspoken motto seems to be like one tattooed on Smith's arm: "Never give up."
Yet loved ones who know the veterans well understand what weighs on their hearts. Smith's aunt, Reanir Stokes, talks to her nephew every night. "He worries about the younger men in the military, what the brain injury is doing to them and if they'll be able to cope with it," says Stokes, who lives in Columbus, Mississippi. "Anthony was seasoned when he was hurt, but many of them are so young. He worries whether the support will be there for them — from their family, their faith, the doctors, and the government."
"I'd study, study, study, and I'd have it. The next morning I couldn't remember a thing."
James David Copeland is a tall, lean, brown-eyed 23-year-old, now living in Munford, Tennessee, who couldn't resist the call to join "the few, the proud." As a lance corporal with the Marines in Falujah, Iraq, blasting away doors and walls was his job. "On a normal day we'd go house to house, waving, shaking hands, asking people if they'd heard gunshots or knew of any bad guys around," says Copeland. "If we got intel about somebody, I'd use my shotgun or explosive to get inside." During his tour of Iraq in 2006-07, he carried out that task "about 50 times." He'd figure out how close he could get without his eardrums bursting. He'd never shoot more than four times because, "I was told if I shot it five times I'd have a brain injury."
Copeland is sitting in a polytrauma clinic at the VA, being interviewed by a medical doctor, a psychologist, a nurse practitioner, and a physical therapist to learn the extent of his physical injuries and to determine if he has TBI. His response to 22 behavioral questions will help in the diagnosis.
When asked about the worst incident of blast exposure, he describes a morning when he and his comrades were guarding an Iraqi prison during a prisoner transfer. "We're hanging out for days, waiting for something to happen," says Copeland. "I wake up at 6:30 to the sound of machinegun fire. Then mortar starts dropping. I'm getting my gear on, running, grabbing my helmet, when a dump truck comes and hits the concrete wall around the building, full of explosives and chlorine gas. Annihilates the truck and the human being inside. Then a second dump truck hits the other side of the building. There's a third dump truck, but by then we're on the roof and somebody shoots the driver, and we go at it with at lot of Iraqis coming after the compound." During the melee Copeland was thrown into a wall several times. He tells staff psychologist John Whirley that he has some amnesia about certain parts of that morning, including how he got down the stairs and out of the building.
Today memory problems plague Copeland. Before his tour of Iraq, he could memorize phone numbers, people's names, Bible verses, school work. He'd completed two years of college, majoring in biology with the goal of becoming a physical therapist. When he got home and re-entered school, he failed every course. "I'd study, study, study, and I'd have it. The next morning I couldn't remember a thing."
Does he have headaches? Yes, at least once a week, and he never had them before.
Blurred vision? A little, when he's tired.
Difficulty reading? "I can read about two sentences, then I'm daydreaming," he replies. "Taking a test takes me longer because I have to keep reading the question over and over."
Copeland works for a pharmacy in Millington as a technician. Though he struggles, he declares, "You don't make mistakes as a Marine. You don't make mistakes in a pharmacy. If you do, someone dies." He triple-checks his work and his co-workers triple-check behind him. Forgetting a customer's name frustrates him most. "They tell me their name, and it's out of my head." Anxiety compounds the problem, so Whirley suggests writing the name down as soon as he hears it.
During the polytrauma clinic session, Copeland also describes his physical ailments, including back pain from hauling around more than his weight in equipment, and a stomach problem that has caused him to drop from 175 to 143 pounds. Dr. Keith Novak, who heads the polytrauma clinic session, tells Copeland they will refer him to a physical therapist and to gastroenterology for evaluation and treatment, either at the VA or at a facility closer to his home in Munford.
As for the TBI, based on Copeland's symptoms and the frequency at which they occur, Novak diagnoses it as "a mild [TBI] and you're handling it pretty well." To further assess and treat his memory function, Whirley says he can receive cognitive therapy at the VA, and use computerized programs at home that challenge the brain.
Copeland, who has been married five months, is scheduled to go to Afghanistan next year. "I have a heartbeat and I can breathe," he laughs. "I'll do what they tell me to do."
Whirley asks a patient advocate who also attends the clinic to see if it's possible for Copeland to get a lateral transfer into the reserves, perhaps as a pharmacy technician. "You don't need any more blasts," Whirley tells the veteran. "War is bad for your brain."
"I can't sleep worth a crap."
Next interviewed by the polytrauma team is red-haired, ruddy-faced Joseph Dytrt. Clad in army camouflage, the 26-year-old from Walls, Mississippi, served 11 months in Iraq as part of a convoy escort. Asked how many blasts he was exposed to, Dytrt pauses, shakes his head, and says, "I don't know, a whole lot." When an IED abolished his vehicle, he knows he was pulled to safety, but was unconscious several minutes after the explosion.
Today, three years later, he has moderate dizziness, ringing in the ears, balance problems, and "I don't sleep worth a crap." When he does sleep, his snoring keeps his wife awake. He struggles to make decisions. Too often he forgets where he's going "as soon as I walk out the door." He also endures debilitating headaches that start at the back of his head and radiate upwards. "Before, I'd get a headache sometimes, but I could take a doggone Tylenol and be fine," says Dytrt. "Now I just deal with it. I have a headache right now."
Relieved of active duty in January 2006, Dytrt worked at the Desoto County Sheriff's Department, until one day he was driving home with his wife and he had a seizure. With medication, the seizures are "manageable." But those moments of being not quite there, of his mind in slow motion, still strike. This past summer, while walking his dog, a man found Dytrt convulsing in the grass. Asked if epilepsy runs in his family, Dytrt frowns and says, "No. Lord, no."
Currently on "light duty," he goes regularly to the Army Reserve center. He joined the service in 1989 and worries about a total discharge. "I don't want that," he says. Meanwhile he's taking human resources courses online. He writes down as much as he can and re-reads the text, but it's hard to grasp. Says Dytrt: "I wasn't like that before." At times, while being interviewed, he's agitated, apologizes for mild curse words, and at one point says, "I'm just nervous in here, okay?"
He's referred to physical therapy for sciatic pain and shoulder pain, and to a sleep disorder clinic. "We see more snoring in patients with brain injuries," says Whirley. He's diagnosed with post traumatic stress disorder (PTSD), which Whirley says he's coping with "pretty well" and with moderate TBI.
Whirley explains to Dytrt how the injury works and how he can help himself: "Think of a landslide. We figure out ways to get around it and where we need to be. With TBI, you give your brain time to repair itself to some extent, and you learn new routes to get new outcomes. The best thing to do is use your brain, challenge it to do new things, but don't get overly tired by pushing yourself. Above all, protect your head."
"Metabolism of cells deep within the brain were altered."
What research is being done to help veterans like Smith, Copeland, and Dytrt, and the thousands more who took blows to the brain and now live with their aftermath? Many of them may look the same, but are their lives irreparably altered? And what can be done to prevent more servicemen and women from suffering TBIs?
To better understand injuries, scientists are finding ways to more effectively study them through imaging. According to the national VA's Rehabilitation Research and Development Department, recent studies show microstructural lesions in the brain's white matter, but the full extent of damage is hard to determine. That's because, unlike the structural damage after a stroke, TBI damage is scattered and not seen easily on an MRI. However, some doctors are combining the use of a conventional MRI with a functional MRI to see if blood and oxygen are restricted to certain areas of the brain. Also helpful is a newer type of MRI known as diffusion tensor imaging, which shows damage to nerve fibers, a crucial component of TBI.
Most researchers agree that, with mild TBIs, the brain to some extent can heal on its own. According to Dr. Michael E. Selzer, a neurologist and head of the VA's Rehabilitation R&D, the brain "rewires" itself as patients relearn and practice skills. He says the nerve cell's fiber — or axon — "can sprout new branches and the branches can travel very short distances. As long as the nerve cells haven't been killed, the brain can rewire its connections to some degree."
Once the nerve is killed, however, there's little hope of recovery. A study by scientists at Johns Hopkins University included blast experiments on rats, followed by microscopic examination of brain tissue. Unlike a concussion, or a bruise on the brain that can heal with time, scientists reported that after blast injuries "metabolism of cells deep within the brain were altered, creating a cascading effect." These alterations could lead to premature aging and death of neurons that cannot be replaced, especially in patients with severe TBI. They can also increase the risk of epilepsy, as well as Alzheimer's, Parkinson's, and other brain disorders that become more prevalent with age.
Scientists, including some at the VA, are looking for a pharmacologic agent that can stop this "cascading" damage. Other studies explore gene therapy and cell transplantation, while another zeroes in on prevention. Scientists with the Naval Medical Research Center in Silver Spring, Maryland, have found a protein that could help protect the brain as well as a compound that could prevent seizures.
In response to the growing number of TBIs among veterans, the Pentagon — which is pouring $5 billion to $10 billion each month into the Iraq and Afghanistan wars — recently announced an unprecedented $300 million for research in 2008 on TBI and PTSD. Some of the money will go toward evaluating TBI medications and ways to regenerate damaged brain cells after exposure to blast waves.
For now, several therapies are geared toward its symptoms. Occupational therapy and physical therapy assist veterans with impaired balance and coordination. Non-steroidal anti-inflammatory drugs (NSAID) and muscle relaxers are prescribed for tension headaches; stronger drugs, such as caffergot, can help severe migraine-like headaches. Some psychostimulants, including Ritalin, have helped sharpen focus and attention span in some TBI patients. But probably the most important therapy is cognitive rehab, which aims to retrain the circuitry in the brain with exercises that work on the memory.
"It's a different animal from physical rehab," says psychologist Whirley. "In physical, you're trying to retrain muscles and joints and you can see if the muscles get stronger. With the brain, you're hoping that activities you engage the person in are going to have some positive effect on all that wiring in the brain. Though we don't have a specific exercise that we can say, 'Do this and your brain will get stronger,' we do have that hypothesis and that hope."
"When They come home, everything is dangerous."
As if dealing with TBI symptoms isn't challenge enough, these veterans may also suffer from post traumatic stress disorder (PTSD). Although the disorder has afflicted warriors from time immemorial — and has been called everything from shell shock to battle fatigue — mental health specialists have come to understand it better after treating many Vietnam War veterans.
"The PTSD has to do with attitudes, beliefs, and expectations," says Whirley, who since 2003 has been working with returning vets from Iraq and Afghanistan. "The veteran will overestimate the danger he's in, or interpret people's behaviors in ways that probably aren't true. TBI aggravates the PTSD, because the brain is slowed down, making it harder for the person to change his thinking."
Sometimes it's difficult to "tease apart" the issues related to each condition. "With TBI, you have trouble with organization, focus, and memory because your brain isn't working well," he says. "With PTSD you have the same things. Plus you're tense, anxious, hypervigilant, aroused, angry. You have nightmares that wake you up at 1 a.m. and paranoia that makes you want to stay home. All that makes it harder to recover from TBI because the brain needs peace, rest, and the chance to get out and learn new things."
For many patients, PTSD's symptoms are worse than TBIs, especially the nightmares. "These people left behind a normal, happy life," says Whirley, a Vietnam veteran, "to go and spend 13 months of terror coming out of the skies. They remember the mortar attacks on the barracks, being on the road every day and wondering if they'd get blown up, bursting into people's homes screaming. They remember driving convoys and having no choice but to run over people who stood in the way, of seeing children shot and killed and blown apart.
"When they come home everything is dangerous," continues Whirley. "Nobody can be trusted. The only safe place is the back room of the house. At night they get up and walk 'the perimeter' while their family sleeps. Any noise is potential danger and threat. These are perfectly reasonable ideas if you're in a combat zone, but they're dangerous and self-defeating here."
Some PTSD patients respond to stress reduction and relaxation techniques, as well as anger and sleep management programs. Others require more intensive therapy.
"Events that have a strong emotional impact get encoded deeply," says Whirley. "Say a veteran is sitting in church, with prayerful people around him, and a little girl walks up to the front and she reminds him of a girl he saw lying on the side of the road on one of his convoy rides. And he's losing it." The therapist's role is to help build trust and create a safe environment for the veteran so he can recall the memory without reliving it. "We really don't want to forget the most important things that ever happened in our lives," says Whirley. "Otherwise we don't understand the changes we go through. We just need to separate memory and emotion."
Homework assignments can help PTSD. For instance, if a veteran thinks he can't trust anybody, "we send him home with a worksheet," says Whirley, "and tell him to write down a situation in which he becomes afraid or angry. Let's say he thought the guy in the car next to him was going to blow him up. The exercise is to come up with evidence for that idea. It happened in Iraq, but it hasn't happened in his hometown. We try to get them to find a middle ground between extremes."
Whirley has seen significant improvement in some veterans — but TBI can aggravate and prolong PTSD symptoms: "The patient will have more trouble regulating emotion, especially anger and impulsive acts. Plus, they may forget their homework assignment once they get home."
While PTSD patients are undergoing therapy, medications can manage their symptoms. These include a blood pressure medicine called Prazosin, which has proven beneficial for nightmares; it suppresses reactions and the person sleeps more deeply. Other drugs prescribed are Prozac, Zoloft, Paxil, and Effexor. "These reduce the patients' overreactivity and anxiety," says Whirley, "and can also help with depression." However, if a veteran has TBI along with stress disorder, such medications could work against the brain injury because "the drugs for PTSD don't improve mental sharpness or thinking power," says Whirley. While the symptoms of TBI and PTSD may overlap, he adds, "what works for one doesn't necessarily work for the other."
"We try to destigmatize the whole mental health issue so they'll get things off their chests."
In a report released in May 2008, the VA's inspector general condemned the overall treatment of veterans with TBI, saying that "significant needs remain unmet." He cited inadequate health care, job assistance, counseling, and ongoing case management, among other problems. The report also stressed the need for combat veterans to know what services they're entitled to.
Dr. Keith Novak can't speak for every VA center, but he does respond for the one in Memphis. As associate chief of staff for ambulatory care and head of the polytrauma clinic, Novak says, "I think we're doing a lot here. We screen every combat veteran for TBI, no matter what they come here for. We have six case managers, three of them in polytrauma to take care of the 300 to 400 TBI patients that have been diagnosed," he says. "About 95 percent of TBI patients have mild cases and they recover most of their brain function. We work with about 50 who still need help overcoming deficits."
While the 95 percent recovery rate is an encouraging statistic, the national VA emphasizes that even veterans with mild TBI cases suffer some permanent damage that puts stress on their personal and family life and makes it hard for them to obtain and keep jobs.
In terms of employment assistance, Novak says the VA sponsors regular job fairs. "Last time we had 22 employers that came," he says. "Our own human resources department staff was there and we've hired 13 veterans to work here. We also have patient advocates who help veterans transition to their new life and to the VA."
To inform combat veterans of services available, ongoing outreach is necessary. Thirty-seven percent of returning Iraq and Afghanistan veterans use the VA; national headquarters would like to raise that number. "We go out to all the different units in our area," says Novak, including those in Jonesboro, Arkansas, and Shelby, Mississippi. "We offer post-deployment health reassessments 60 to 90 days after discharge. We recently enrolled 100 veterans from Brownsville and 400 from Jonesboro, getting them appointments here. We go to family support groups, we send letters, and we have Welcome Home events for all returning vets."
Novak affirms a positive outlook. "We try not to use the term brain injury," he says. "We use concussion." He considers this a way to reassure the patients, "to get them out in the world and active and feeling better about their situation." At the same time, he encourages them to discuss their troubles and concerns.
In 2004, the Memphis VA set up some of the first combat veteran clinics in the U.S. "At these clinics we try to destigmatize the whole mental health issue so they'll get things off their chests," says Novak. "They see and hear their buddies there. They realize they're all having problems. That makes them more willing to get treatment."
"They think, 'My buddy lost his leg but all I've got is a splitting headache.' To them we say, it's okay. We can help."
Carol Bertsch agrees that veterans may be reluctant to seek help for symptoms. As chief of physical therapy at the VA, she has seen firsthand that physical activity and a competitive spirit can help veterans overcome deficits. But first you have to get them to come in.
"In some respects, it's pride," she says. "They think, 'My buddy lost his leg but all I've got is a splitting headache.' To them we say, it's okay. We can help."
Some feel isolated, she adds. "They've been running 90 to nothing for six months to a year, with specific duties. They come home and life seems so trivial. Family members complain about a bad-hair day.
"With others it's just a general hurting all over," Bertsch continues. "We have a 20-year-old who says he feels like 60. These veterans go to bed hurting and wake up hurting. Sometimes we can identify the problem, but for others, there's no way to pinpoint the reason for their feeling except exposure to that blast wave."
Among the TBI symptoms that she treats are balance abnormalities. Veterans will get dizzy or lightheaded and it may take them awhile to reorient themselves. "We have a Biodex balance system, which is a great tool for helping us assess whether their center of gravity is displaced," says Bertsch. "The only way to improve their balance is to challenge it. It's a matter of retraining."
Sometimes, she adds, the problems can't be fixed but education will help the patient adapt to deficits: "When one sense is decreased, others are improved. If a person stumbles in the night going to the bathroom, we teach them how to use other senses."
The VA also provides GPS systems to help veterans who get lost in traffic, and PDAs to help them remember such daily chores as taking their medications and paying their bills. "These younger vets are electronically savvy so they love the PDAs," says Bertsch. "For others we'll provide calendars and stress the importance of keeping lists and posting reminders to themselves. It all improves their brain and memory."
He misses the way his memory used to be."
On a visit to the VA physical therapy department one morning, Major Anthony Lamar Smith empties a backpack filled with various attachments for his prosthetic arm, as well as T-shirts and totebags — gifts for Bertsch and other VA staff. He recalls when he first came to see the 46-year-old therapist. "She'd tell me, 'Here's what we want to do, leg lifts, leg slides, windshield wipers.' I'd say that's cool, then my mind would just forget it. She kept having to remind me."
Though he still gets physical therapy at the VA, he handles cognitive retraining on his own. Vital to keeping his life in control is constant repetition. "You stay with me three days, you know I'm gonna do the same thing." That repetition, along with the notes, the PDA, journal writing, and a determined spirit keep Smith going. His faith and a little help from his friends give an extra boost. "I'm Pentecostal, and have a lot of people praying for me. So even with my wife and younger kids gone, I still have a good support group."
Though some days require Herculean efforts, Smith insists the good moments outweigh the bad. "I have this mindset that I don't let a situation overtake me," says Smith. "I read how I'm feeling and how I'm gonna work through the day. Sometimes I back off and let my body and brain rest and adjust."
Although he collects Army pay and VA disability payments, he wants to work, to be useful. For a short time after he returned to Blytheville, he served as the police chief in a neighboring town. "They found out about my TBI and let me go," says Smith. "Once anyone sees my medical record, that's it." Meanwhile he volunteers and gives motivational talks to a sports organization for the disabled, and is trying to get a job at the Memphis VA. Several times a month he sees doctors and therapists there. Though his TBI is still considered severe, "they say I have it under control," says Smith.
Bertsch has seen what war does to the bodies and minds of veterans from Iraq and Afghanistan, and she observes how they struggle. "They have a lot of issues. Some adjust, some don't. Anthony has definitely adjusted. I have never heard him once blame anybody."
For his aunt, Reanir Stokes, thinking of Smith's younger years makes her smile. She recalls how he competed fiercely in football, track, basketball, karate. How much he loved his grandmother, who died in the 1980s. How, as a ROTC student and graduate of Alcorn State University in Mississippi, "he was smart, confident, and made his opinion heard."
After the injuries sustained in Iraq, this young man who'd done well in math suddenly couldn't add two plus two. But he taught himself basic sums and slowly began to read again. He learned to write with his left hand. Today, she adds, "the computer is his best friend."
Every night, often at 3 or 4 a.m., Smith calls his aunt. He may have a bad headache or insomnia or both. "We'll talk till his head quits hurting or one of us falls asleep," she laughs. "He'll tell me what's on his mind, about the young men in the military and how they're having to cope with [TBI]. He's made tremendous progress, that's for sure, and he stays upbeat. But he misses the way his memory used to be. It bothers him still."