Walter Reed's World of Hurt, Hope

"We've got some complicated guys on the floor right now," Clarisa Nichols answers. She does not elaborate.

She is 24, and the hospital is her first duty station out of nursing school. She is assigned to Ward 57, the busy orthopedics unit once populated by older men and women recuperating from knee surgeries or hip replacements. In more than two years, 1st Lt. Nichols has seen virtually no such patients.

What she has seen are soldiers around her age, with massive pin-and-bolt armatures securing fractured bones or thick dressings covering raw stumps. They may be brought onto the floor with desert sand in their hair or spilling from their gear, and suddenly Iraq seems even closer. Nichols could be sent with scant notice to a combat support hospital there. Overseas duty is a matter of when, not if.

She will be ready. Her responsibilities at Walter Reed have made sure of that. At first, she questioned whether she would be able to handle them -- not so much emotionally as technically. Would she have the skills to do the job? She found herself tested on both fronts, staggered initially by the influx of casualties and challenged by their worst injuries.

"Sometimes," she says, "I'll go back to our break room and take a couple deep breaths. I'll think, 'Is there anything else I can possibly do?' "

Sometimes there is not. No more medicine she can offer, no relief other than a repositioned pillow or appendage. A patient Nichols will never forget, a soldier from the foreign forces assisting the United States in the fighting, writhed for hours one night. He spoke no English and would look at her uncomprehendingly. "There was no way I could reassure him," she says. "It was just one of those times; I sat down and held his hand. I felt helpless."

She balances that memory with the moments when patients took their beginning steps on a new prosthesis or returned with a smile and big hug after discharge. The nurses keep a bound book listing all the patients on the unit from December 2003, and on a slower shift, they'll get nostalgic looking through the pages. All told, the hospital has treated 323 amputees from Iraq and Afghanistan.

It also has seen the deaths of 11 service members.

"I can't believe how long it's been happening," Nichols reflects one afternoon. She has a younger brother in the Navy and a younger sister in the Army. "It's still hard to see an 18-year-old come in. Every so often, you wonder when it's going to end."

The number of battle casualties at Walter Reed fell to 408 during the third year of Operation Iraqi Freedom, compared with the more than 520 in each of the previous years. The trauma that sent them there -- frequently so extensive that the military coined the term "polytrauma" -- did not diminish.

Few wounds now hold the same shock factor for the hospital's surgeons. Col. Craig Shriver, who heads the general surgery department, remembers the teams of residents who came to him in late 2003 after their overnight rotations in the OR. "Three months is enough," they told him.

Recent teams have reacted far differently, though their chief doubts they are any tougher. More likely, after hearing and reading accounts of the injuries, they simply have been better fortified. "Maybe they've come to expect it," he says. As they are deployed, these new doctors will take their training directly to the troops.