National Geographic : 2006 Dec
Another major problem, Lux says, centers on self-awareness. Many brain-injured patients don't recognize that they're injured or that they have lost pieces of themselves. "Part of what you need your frontal lobes for is to figure out who you are, because you need that to plan your way in life. Your self-image is built in your frontal lobes. That means that people who have all the skills to do things in the world won't use them because they don't know that they have to." In the most common, and simple, form of brain injury, called a concussion, the brain usu ally regains normal function quickly. When it cannot self-repair, the brain sometimes rewires, routing signals along new channels, across its backup networks of axons. There are limits to this. The brain contains a finite number of axons. Brain matter, if it regenerates at all, grows very slowly. Repair takes time, weeks or months or even longer. Rehabilitation seems to work best when it occurs almost simultaneously, spurring the brain to form new connections, and the injured to learn new ways of thinking, acting, living. If rehab doesn't follow soon after injury, recovery is less likely to succeed; it may even become impossible. Soldiers diagnosed with TBI proceed along separate paths depending on the severity of injury: mild, moderate, or severe. Moderate and severe patients are transferred to one of four special hospitals run by the Department of Vet erans Affairs. There they receive long-term care and therapy. Patients with mild TBI may be sent home, back to duty, or, if they need additional rehabilitation, to community-based centers that focus on rebuilding their mental abilities. After nearly a month at Walter Reed, Jason Welsh was sent to Virginia NeuroCare, a small, private clinic in the rich green hills of central Virginia. It is a Thursday morning in early August, and the merciless wet heat of a Virginia summer hangs over Charlottesville. The city is peaceful, collegiate, home to the University of Virginia, and close to Thomas Jefferson's home at Monticello. In the tangled brush, the overgrown forests, and stubbled fields nearby, tens of thousands died in 104 NATIONAL GEOGRAPHIC * DECEMBER 2006 Civil War battles at Fredericksburg, the Wilder ness, and Chancellorsville. To reach Sgt. Jason Welsh, you must steer past them all. Welsh sits in a small office, still wearing a neck brace, and tries to write a grocery list. An occu pational therapist named Joy Sandlin helps him. He chooses food for a week of meals. But Welsh has never lived alone or cooked much for him self. Since his arrival at Virginia NeuroCare, he has lived in a group home with other brain injured patients, some of them soldiers. His TBI has reduced his ability to focus and remember. "Jason's going to need to learn to shop for himself and eat healthily," says Sandlin, a petite young woman with long black hair. "One of the things is that he's a 25-year-old guy who moved directly from his mom's house to the Army. He's never had to do this before, and he doesn't nec essarily care. But it's something an adult needs to do, and the skills go way beyond breakfast." The exercise is one of planning, navigation, memory, and execution. Eventually, he'll travel to the grocery store using public transportation, remember why he's there and what he needs, and then gather and buy it. Simple tasks requir ing a thousand minute computations. Sandlin scans the list-ramen noodles, peanut butter, Honey Nut Cheerios. She asks questions, forcing Welsh to concentrate, probing his mem ory. She taps the list with her pen and says, "What do you think you'll want to drink besides Coke and milk?" Welsh's injury was relatively mild. The MRI revealed "diffuse axonal injury"-shearing and twisting of axons-mainly in the right lobe, and some in the left. After the injury, portions of his brain had difficulty communicating, signals were interrupted, the network damaged. He has had problems with memory, multitasking. He loses focus, and sometimes his temper flares erratically. He curses more, and his sense of smell and touch have weakened. Welsh also suf fers survivor's guilt, especially about Crombie. "I let him down," Welsh says. "I didn't even know him long enough to learn anything about his personal life."