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Traumatic brain injury leaves an often-invisible, life-altering wound

The military brass are discovering that what used to be shrugged off as "getting your bell rung" can lead to serious consequences. In some cases, even apparently mild brain injuries can leave a soldier disqualified for service or require lifelong care that critics say the Department of Veterans Affairs isn't equipped to handle.

Since 2000, traumatic brain injury, or TBI, has been diagnosed in about 180,000 service members, the Pentagon says. But some advocates for patients say hundreds, if not thousands, more have suffered undiagnosed brain injuries. A Rand study in 2008 estimated the total number of service members with TBI to be about 320,000.

A small percentage of those injuries are as serious as Warren's. To let his brain swell and keep the blood flowing, thereby preventing the damage from worsening, doctors removed virtually the entire left side of his skull, a procedure known as a craniectomy.

Warren's physical wounds will heal, but three weeks after he was hit, military doctors are still discovering the extent of the damage.

Williamson plows ahead with other tests, revealing that Warren doesn't know where he is. "This is the U.S.A.?" he says. Warren cannot subtract seven from 135, but he can spell "world" - though not backward. He can recite the days of the week but can't come up with the words for necktie or button.

Finally, Williamson asks whether he can remember those three words he had to repeat. Sixteen minutes and 19 seconds have passed.

"Which words?" Warren says.

The patients on 7 East

No two traumatic brain injuries - signature wounds of the wars in Iraq and Afghanistan - are the same, but the patients on 7 East, Williamson's TBI unit, demonstrate what life is like when the organ that turns a body into a person is damaged.

There's the Marine whose injury robbed him of the ability to understand speech even though he could still read, another who could no longer laugh, one who could see out of both eyes but only to the left, and one soldier who became dangerously impulsive and started spending thousands of dollars on junk he didn't need.

Although their injuries might not be as visible as a severed limb, TBI victims' damaged neurons and altered brain chemistry can cause all sorts of behavioral problems. Those injuries are about much more than a lump of tissue sitting between the temples. "It's about who they are," Williamson says. "How they see the world. How they process different experiences. It's about how their personality changes. It's about their humanity."

Many patients on 7 East suffer from little more than the general haziness that comes from having been too close to an explosion. Those concussions, often referred to as mild TBI, are the most common brain injuries in wars in which the enemies' weapon of choice is the makeshift bomb.

Severe TBI, such as Warren's, can lead to wholesale personality changes. But doctors now know that even mild TBI can have serious consequences. A blast "causes a change in how your brain functions," said Vice Adm. Adam M. Robinson Jr., the Navy surgeon general. "People have been very, very slow to come to that conclusion, but it's true."

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