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American troops who suffer serious injuries in Iraq are considered to be at risk for another kind of injury when they get home. Doctors are watching for signs of mental health problems. As part of our Span of War series, NPR's Joseph Shapiro reports.
JOSEPH SHAPIRO reporting:
If you've ever lived or worked on a US Army base...
Unidentified Woman #1: Right, left.
SHAPIRO: ...you may notice what's missing from this scene.
(Soundbite of bugle)
SHAPIRO: It's the end of the day at Walter Reed Army Medical Center in Washington, DC, time for soldiers in camouflage to lower the American flag.
(Soundbite of bugle)
SHAPIRO: It used to be that a cannon went off, but the cannon is covered in a green tarp. At Walter Reed, they stopped shooting the cannon after some soldiers complained the booming sound triggered flashbacks of attacks in Iraq.
Not firing the cannon is just one of many small things done at Walter Reed, all to prevent some of the psychiatric injuries of war. Doctors here counted up how many of their war-injured patients have psychiatric problems. They were shocked that so few did.
Dr. THOMAS GRIEGER (Walter Reed Army Hospital): I kept checking it because I was surprised that the numbers were as low as they were. Based on experiences with prior wars, based on experiences in civilian populations, I wanted to make sure that we were accurate.
SHAPIRO: That's Dr. Thomas Grieger. He had every reason to expect high numbers with post-traumatic stress disorder. People with PTSD may have nightmares and flashbacks that can be triggered by a loud noise or some reminder of a past trauma. Other research had already shown people in serious car crashes, soldiers shot in war--about a third will develop PTSD. And last summer, another psychiatrist at Walter Reed published a study of troops back from Iraq. They did not have severe physical injuries, but still many of them were depressed, anxious, or had PTSD--17 percent of them.
Dr. GRIEGER: So we were expecting rates initially at least that high and actually expecting rates significantly higher than that as a result of these individuals being both exposed to war and being physically injured in war. So that's what we were expecting, and that's not what we found.
SHAPIRO: Grieger followed more than 600 patients at Walter Reed, men and women who'd lost arms and legs. Some had brain injuries, others were blind or paralyzed, but few developed PTSD. In Grieger's study of injured soldiers at Walter Reed...
Dr. GRIEGER: 4.2 percent met criteria for post-traumatic distress disorder.
SHAPIRO: Just 4 percent, not anywhere near the one-third of civilians injured in car accidents or even the 17 percent who came back from Iraq without physical injuries. Grieger is a psychiatrist at the military's medical school, the Uniformed Services University of the Health Sciences. His study does not speculate why so few patients at Walter Reed developed PTSD.
Unidentified Man #1: I went down through...
SHAPIRO: But walk around the hospital, and you get an idea. Start in the busy physical therapy room.
Unidentified Woman #2: So we're going to do that one more time, and we're going to pick up that left foot.
SHAPIRO: Men and women who lost legs and arms work out on exercise machines with therapists. Almost everyone has a mother, father, a wife, or a girlfriend, even their babies at their side. There's lots of family support. And the soldiers and Marines here are young and athletic. To get better is another mission. They approach it with a can-do spirit and often with humor. One soldier's shirt says, `I lost my leg in Iraq and all I got was this cruddy T-shirt.' Here an amputee can look across the gym, and there's someone with the same injury or worse, only they're already walking or even running on their prosthetic leg. So they encourage each other, like this Marine who's been on his new leg for weeks now. He spots a buddy who's just trying out his.
Unidentified Man #2: You look good, man. You'll be ready to be playing football soon.
SHAPIRO: Harold Wain runs the psychiatric team that works with injured soldiers. He's got a term for this.
Mr. HAROLD WAIN (Walter Reed Army Hospital): The womb of Walter Reed. It's the overall nurturing that the hospital gives them.
SHAPIRO: When Wain talks about the womb of Walter Reed, he means the way the injured get whatever support they need from the most advanced prosthetic legs and arms to the closest attention from the psychiatry staff, only they call themselves preventive medical psychiatry with the emphasis on preventive. Wain says it sounds less stigmatizing. On this day, Wain introduces one of his patients.
Mr. WAIN: This is Corporal Nathan Webster, one of our heroes coming back from Iraq who was severely injured. And he's done a wonderful job and we're very impressed with how he's handled himself.
SHAPIRO: Webster is 23, a large man with a round face and reserved manner. He's a Native American.
Corporal NATHAN WEBSTER (Injured Soldier): I'm from Omaha, Nebraska, part of the Omaha tribe of Nebraska.
SHAPIRO: Around his neck, Webster wears a narrow gleaming piece of metal with a row of holes. It's a souvenir from his last surgery. Wain explains.
Mr. WAIN: This is actually a plate that he tells me came out of his arm, came out of his elbow. And he's waiting for the other one to come out so he can give it to his mother.
Cpl. WEBSTER: I think it's titanium plate that they put in my elbow because my elbow's someplace in Iraq.
SHAPIRO: In December, Webster's convoy came under attack. He lost a large part of his right arm from midway above the elbow to midway below.
Cpl. WEBSTER: When it blew up, my hand, my right hand, slapped me in the face, and I couldn't move it. So I just knew right then and there that it was like, oh, man, my arm's gone. Plus, to have my face so covered in blood and some oil and stuff from the IED...
SHAPIRO: Within 48 hours after Webster arrived at Walter Reed, a member of Wain's staff walked into his room just to say hello. Webster wasn't interested in talking then or for months later. He'd stay in bed. He stopped shaving. He didn't get dressed. Webster's one of the few among the injured who also got diagnosed with post-traumatic stress disorder.
Cpl. WEBSTER: I was really withdrawn. I wouldn't talk to nobody or anything like that. I mean, I was really anti-social when I first got to Walter Reed because I was probably feeling sorry for myself.
SHAPIRO: That's natural. So Wain kept coming back. He waited for a moment to break through. The psychiatry team doesn't always succeed. Amputees and the seriously injured fight infections, persistent pain, and prosthetic devices that don't quite fit. There are moments of despair. Among a separate group, the patients who come here with just mental health problems, there have been a few suicides. Dr. Steven Cozza runs psychiatric services at the hospital. He says what psychiatrists do at Walter Reed is different on purpose.
Dr. STEVEN COZZA (Walter Reed Army Hospital): Unlike what people think of a psychiatrist in terms of being not very active, listening, not providing a whole lot of feedback, the folks on the consulate liaison service are very active; they use humor; they develop relationships, they talk with them just, you know, like people, not like as a psychiatrist, and just talk with them about how life is going. And over time, they're more likely to trust you to talk with you about those things that are more troubling to them.
SHAPIRO: It was a corny joke that got Nathan Webster to open up. Doctors at Walter Reed grafted a nerve to his reconstructed arm. But to work, his right arm had to be sewn to his side.
Cpl. WEBSTER: For three weeks my arm was attached to my side. And that's when I started remembering Dr. Wain, mostly because he used to call me Napoleon because it looked like I had my arm in my jacket all the time. So when called me Napoleon, that's when I first started talking to him.
SHAPIRO: Wain gave Webster an invitation.
Cpl. WEBSTER: I started going to the luncheons.
SHAPIRO: The luncheons are every Tuesday and Thursday. It's actually group therapy with sandwiches.
Cpl. WEBSTER: And just started talking to them, and eventually over time I came out of my shell and started to become more social.
SHAPIRO: With the help of that therapy, support and medication, Nathan Webster is managing the effects of his PTSD. He started thinking about his future. He talks of going to college and maybe to law school.
Dr. Grieger, who did the study, says it's expensive for all the staff needed to give this level of care. Grieger followed his patients over time, and he found something else that was different.
Dr. GRIEGER: Typically, with post-traumatic stress disorder, the rates are highest initially, and then they continue to drop across time.
SHAPIRO: But at three and then six months after injury, the number of patients with PTSD tripled. Often PTSD developed after they'd left Walter Reed. Grieger says it's not clear why. Perhaps the injured find it hard to adjust back home, or get frustrated when their health problems don't go away. But many find it's hard to recreate what made Walter Reed a good place to start their recovery from injury. Joseph Shapiro, NPR News.
INSKEEP: This is MORNING EDITION from NPR News.
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