After Severe War Injuries, a New Battlefield

By Tony Perry, Los Angeles Times

08 May 11

Troops with severe war injuries such as multiple limb loss face a long and difficult rehabilitation. Naval Medical Center San Diego is where some learn a new way of life.

arine Lance Cpl. Juan Dominguez has come a long way since October, when a roadside bomb in Afghanistan ripped off his legs above the knees and shredded his right arm above the elbow.

A Navy corpsman, part of the same patrol, kept Dominguez from bleeding to death and wisely refused his pleas for morphine, lest he go into shock. Then there was the Navy doctor at nearby Forward Operating Camp Dwyer who "wouldn't let me die" and the intensive care he received at Landstuhl Regional Medical Center in Germany.

After that, Dominguez spent five months at the National Naval Medical Center in Bethesda, Md., and at Walter Reed Army Medical Center in Washington, DC, where he underwent 23 surgeries. Today, the 26-year-old from Deming, NM, is an outpatient at Naval Medical Center San Diego.

"This is home now," he said of the hospital on a hill beside Balboa Park.

Dominguez is among a growing number of Marines and soldiers who have suffered catastrophic wounds that will require years of care in military hospitals. The Pentagon and the Department of Veterans Affairs are scrambling to put together a continuum of long-term care for Dominguez and other severely wounded personnel.

Based on what trauma doctors call the Injury Severity Scale index, the average score for battlefield casualties brought to the Landstuhl intensive care unit is at its highest level in the nearly 10 years that the US has been at war, Landstuhl's top trauma surgeon, Air Force Lt. Col. Raymond Fang, said last week.

"These patients are young, they are fit, and they have the best protection available right now, but their injuries are very severe," Fang said.

The number and rate of double- and triple-amputees have risen dramatically in the last 18 months. So has the number of military personnel suffering wounds to the genitals and urinary tract.

The most grievous wounds are traceable to the Taliban's continued use of improvised explosive devices. US counter-insurgency strategy calls for soldiers and Marines, whenever possible, to go on walking patrols rather than ride in armored vehicles - increasing their vulnerability to buried roadside bombs.

The Army surgeon general, Lt. Gen. Eric Schoomaker, has formed a Dismounted Complex Blast Injury Task Force headed by Brig. Gen. Joseph Caravalho Jr., a cardiologist and commanding general of Brooke Army Medical Center in San Antonio. Its report is due in weeks.

The task force, including 27 medical experts, is charged with going beyond trauma medicine and examining "all the optimal acute management and rehabilitation of these more severely wounded warriors, including pain control, psychological and spiritual support, and family support."

At Naval Medical Center San Diego, patients are seen by doctors and therapists from a wide range of specialties. Outpatients like Dominguez live in two-person rooms on the hospital grounds.

Dominguez arrived a month ago. Days later, the corpsman who had saved his life, Stuart Fuke, 22, of Honolulu, arrived directly from Landstuhl; he had been shot in the thigh while on foot patrol.

Programs never dreamed of when the US invaded Afghanistan in 2001 and Iraq in 2003 are now part of the San Diego regimen for wounded personnel, including a full range of sports activities, counseling for family members and group discussions with Vietnam veterans.

Dominguez is looking forward to a surfing trip to San Onofre. He'd like to run in the Marine Corps Marathon once he is fitted and capable with his permanent prosthetic legs. Part of his therapy will be relearning to play the guitar.

"My plate is pretty much busy from morning until dark," he said.

Dominguez sees a dermatologist, ophthalmologist, neurologist, vascular specialist and primary care physician, among others. He receives occupational and physical therapy and sees mental health specialists for post-traumatic stress disorder and traumatic brain injury. He's had surgery to regain the hearing in his left ear.

He underwent what doctors call a fractional carbon dioxide laser surgery to shape his scar tissue, promote healing and soften the tissue in order to improve the tolerance for a prosthetic limb. More than 500 such treatments have been done on amputee patients at Naval Medical Center San Diego in the last two years.

Dominguez's mother, Martha, lives in an adjoining room in the battalion housing and accompanies her son to his appointments. Several other mothers live in rooms beside their wounded sons.

Navy and Marine Corps brass have agreed that wounded Navy corpsmen should live on the same floor as the wounded Marines. Both groups recover more quickly when they are near personnel who share their battlefield experiences, officials said.

Fuke and Dominguez, for example, are part of the Camp Pendleton-based 3rd Battalion, 5th Regiment, which was assigned to the Taliban stronghold in Sangin. "He's one of my boys," said Dominguez, adding that he has finally forgiven Fuke for not giving him morphine as he lay in the dirt writhing in pain.

From the beginning of the assault on Baghdad in 2003, the San Diego hospital has treated patients with traumatic amputations. But last year, particularly as the battalion fought the Taliban in late fall, the numbers surged to unprecedented levels.

In 2010, the San Diego hospital received 31 patients who had undergone amputations, a three-fold increase over 2009. In the first four months of 2011, 18 more patients with amputations were transferred to San Diego.

In 2009, only one of the 10 amputees had lost more than one limb. In 2010, the figure was 10 of 31. So far in 2011, the figure is 11 of 18.

In all, the hospital has had 99 patients with amputations from Iraq and Afghanistan. From those cases, doctors and therapists have devised improved methods for building and fitting prosthetic limbs.

Along with an increase in amputations, there has been an increase in severe wounds to the genitals and urinary tract. In that regard, Dominguez counts himself lucky.

A shard of metal came within a fraction of slicing his testicles. He survived unscathed. "God must have had his hand on me," he said.

Other Marines and soldiers have not been as fortunate. Their wounds are different from those suffered by patients in traffic accidents or other civilian mishaps, doctors say.

"It's unusual for us to see these kinds of genital mutilation," said Navy Cmdr. James O. L'Esperance, a urologist at the San Diego hospital. "We've all done some reconstructions."

Caravalho said he is confident that from their recent experiences, military doctors will soon publish articles in medical journals on "how best to salvage testicular function."

Meanwhile, the Marine Corps plans to send blast-resistant underwear to Marines in Afghanistan to protect their genitals and femoral arteries.

Although the new "blast boxers" will not make Marines immune to improvised explosive devices, they are meant to prevent dirt and shards of metal from being embedded in a wound and causing an infection.

In November, Dominguez told The Times that he occasionally wished he had died in Sangin. Those kinds of thoughts now seem largely gone, replaced by a pride in what his battalion accomplished there.

"The Taliban failed," he said. "Their purpose was to kill me. I survived."

To walk the grounds of Naval Medical Center San Diego is to see numerous Marines, soldiers and sailors like Dominguez, in wheelchairs or with prosthetic limbs, many accompanied by spouses or parents and sometimes young children. More seem to arrive daily as the fighting in Afghanistan intensifies after a winter lull.

"It's part of our life; it's all around us," said L'Esperance. "You can get used to it.

"I hope we don't."