washingtonpost.com
Walter Reed's World of Hurt, Hope
Suffering of Iraq Casualties Takes Toll on Hospital Staff

By Susan Levine
Washington Post Staff Writer
Wednesday, April 5, 2006

Solomon Montgomery wakes up early on workdays. Hours before dawn, the first thing he does is pray.

He prays for the soldiers he will try to help that day, whose bodies were ravaged during attacks in Iraq. He prays that their families find comfort and courage. And with no end to the bloodshed in sight, he asks God for support. "Lord," he says, "give me the strength to do my job."

At 7 a.m., he reports for duty at Walter Reed Army Medical Center. The war remains ubiquitous in the operating rooms, some of which are set aside for the returning wounded, and on the wards, where amputees begin coming to terms with their new realities. Montgomery, a physical therapy assistant with the bulk of a former defensive end, works in a ball- and mat-filled space where, hour after hour, he challenges and cheers on brain-injured soldiers not much older than his own teenager.

So many have arrived in the past three years -- so many continue to arrive -- that they have transformed the hospital's routine. The staff has been redeployed, programs created, a special military company activated just for the injured. "This has become our normal," a nurse explains. But the cumulative effect of nearly 4,900 patients, including 1,458 battle casualties, has done more than change the institution. It has deeply affected the hundreds of doctors, nurses and therapists who work there -- who have been inspired by the resiliency and motivation of the individuals in their care, yet shaken and exhausted by the magnitude of loss.

Since the first soldier was admitted March 28, 2003, nine days after the invasion of Iraq, Walter Reed has confronted damage of daunting proportion: limbs blown off, guts blown open, brains devastated by piercing shrapnel or by concussive explosions, or maybe all that and more. The youth of the wounded elicits sadness, even tears. The veteran staff members look at these patients and see their sons and daughters. Their younger counterparts see siblings, friends.

"That's always my worst nightmare, that I'm going to take care of someone I know," says Capt. Matthew Hueman, a 31-year-old surgical resident whose West Point class has suffered casualties in the war.

Six thousand miles from the actual mortar fire, grenades and roadside bombs, it amounts to a different kind of combat fatigue.

At the start, they expected that the transports of casualties would taper off quickly. But three times a week, the white buses from Andrews Air Force Base still turn off Georgia Avenue NW through the hospital's main gate. They pull slowly up the looping drive to where a double line of gurneys and a small company of gown-clad escorts wait, and then each bus's back door swings open, revealing the litters of patients. Some soldiers are only 48 hours off the battlefield. The most critically injured are unloaded with so much medical equipment they are scarcely visible beneath it.

A pause to lower a litter, convey charts and untangle tubes, and then the new arrival is whisked inside, under the Walter Reed banner proclaiming "We provide warrior care" and on to a triage room.

That pause is all Michael Wagner needs to say, "Welcome home."

Over the past 2 1/2 years, the chief of the hospital's Medical Family Assistance Center estimates that he has greeted hundreds of patients, as well as thousands of family members. His first weeks, he struggled to find the right words. "This guy's missing a leg. What do I say to him?" he wondered. Until he understood: "They're not legs, they're not arms. They're human beings."

These days, the psychologist talks to spouses and parents with a gentle bluntness.

"How you doing?" he asks.

"Fine," they invariably say.

"How you doing?" he asks a second time.

"Fine," they repeat.

"Baloney," he says.

At which point family members usually cry. "You have to permit them to feel their hurt," he says.

Wagner, 56, is a retired Army colonel who joined up during the Vietnam War. After the 2001 terrorist attacks, he tried to volunteer anew, ultimately connecting with the command at Walter Reed and moving from Arizona to run interference for soldiers' families. At the assistance center -- established in response to the casualties' protracted presence -- he has been asked to secure everything from a massage to mortgage money. When all guest accommodations on post are filled, he persuades local hotels to provide rooms at no charge. "I need you to be a good American here," he tells hotel managers.

Still, 12-hour days consumed with strangers' needs are draining. Last fall, he finally realized how tired he was, "tired of seeing the wounded come in, young men and women in the prime of their lives, coming back ripped apart. . . . It was overload, burnout, whatever you want to call it."

The stress, he says, "wears on everybody in this hospital."

Wagner has learned how to take time off, how to get on his Harley and ride out of the city, into rural stretches of Maryland. He's reached a different place, not necessarily numb to the pain around him but able to put it in a broader context. "This is our normal," he says. "Our mission."

When he leaves the hospital grounds, which will receive soldiers until Walter Reed moves to Bethesda in several years, he finds himself looking for people with missing limbs. Their absence seems strange.

Her parents back in Washington state worry, but they don't press her for details. "How's life on the ward?" her mother will say, vaguely enough.

"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.

Shriver himself has more than two decades in the Army and two tours as a combat surgeon. At 47, he could retire tomorrow. The reason he stays: As long as the conflict drags on, and the buses from Andrews return with their damaged cargo, he feels an obligation "to finish the job."

The last several years at Walter Reed have been the most demanding of his career. They've also been among the most humbling and rewarding. He marvels at the soldiers' attitude, their gratitude, their perseverance.

"What this has taught me is, our youngest generation is magnificent," he says.

It has renewed his faith in America.

By 10:40 in the morning, Solomon Montgomery is halfway through a set of balance exercises with 20-year-old Pfc. Daniel Perry of Somers, Conn.

"Move the top of your body," he says. "Give it a good stretch."

Bluish traces of shrapnel dot the left half of the soldier's pale face, betraying the blast that left him unconscious in an Iraqi bunker 27 days earlier. Perry met Montgomery when he was barely able to stand, unable to walk, incapable of following all but the simplest commands and angry and confused. He tried to kick the big guy, more than twice his size and age.

"Looks like this boy is going to be fun to work with," Montgomery responded cheerfully.

His PT unit focuses on those with traumatic brain injury. Before the war, it didn't exist. No need for it.

"I didn't realize what I was getting into," concedes Montgomery, a civilian employee who came to Walter Reed in 2000. During their time together, he has watched Perry make steady progress. Other patients have not. Two years ago, he was assigned a brain-injured soldier in his early twenties, a father of three whose youngest child had just been born. The man could neither hold nor see his baby: He had lost both arms and his eyesight.

Montgomery drove home that afternoon and went to bed. He stayed home the next day. He couldn't go to work; he couldn't even get out of bed. The tragedy seemed too overwhelming.

He has since found deeper reservoirs of strength -- his church in Brandywine, his Bible study group, his high school daughter, who senses when to ask, "Daddy, is the war bothering you again?" The war has brought them closer. The war, in fact, "has helped me grow to be a better man."

He pauses. There is more.

"It's made me realize how precious life is," he says, "and the price you pay for freedom."

View all comments that have been posted about this article.

© 2006 The Washington Post Company