“You keep doing your job with your injuries,” said Mr. Owsley, 47, an Indiana reservist who served as a gunner for a year outside Baghdad beginning in March 2004. “You don’t think about it.”
But more than three years after coming home, Mr. Owsley’s days have been irrevocably changed by the explosions. He struggles to unscramble his memory and thoughts. He often gets lost on the road, even with directions. He writes all his appointments down but still forgets a few. He wears a hearing aid, cannot bear sunlight on his eyes, still succumbs to nightmares and considers four hours of sleep a night a gift.
Mr. Owsley is part of a growing tide of combat veterans who come home from Iraq and Afghanistan with mildtraumatic brain injuries, or concussions, caused by powerful explosions. As many as 300,000, or 20 percent, of combat veterans who regularly worked outside the wire, away from bases, have suffered at least one concussion, according to the latest Pentagon estimates. About half the soldiers get better within hours, days or several months and require little if any medical assistance. But tens of thousands of others have longer-term problems that can include, to varying degrees, persistent memory loss, headaches, mood swings, dizziness, hearing problems and light sensitivity.
These symptoms, which may be subtle and may not surface for weeks or months after their return, are often debilitating enough to hobble lives and livelihoods.
To this day, some veterans — it is impossible to know how many — remain unscreened, their symptoms undiagnosed. Mild brain injury was widely overlooked by the military and the veterans health system until recently.
Even now, with traumatic brain injury called the signature injury of the Iraq war, some soldiers and their advocates say that complications from mild concussions often are not recognized.
Mr. Owsley’s request for a Purple Heart, given to troops wounded or killed in action, was denied by the military, a devastating blow. Others say that their mild brain injury entitled them only to low disability payments, or, if the diagnosis was inconclusive, to none at all.
This has happened in large part because there is no quantifiable diagnostic test for the injury, and the language used by the Veterans Affairs Department to rate traumatic brain injury, or T.B.I., is vague. The military, in particular, seldom rates each symptom from a concussion separately, which it is required to do, said Kerry Baker, associate national legislative director for Disabled American Veterans.
“The criteria remains ambiguous,” Mr. Baker said. “The military way underrates T.B.I. and its symptoms.”
Scant Medical Knowledge
Little is known medically by doctors or scientists about what happens to a brain as a result of a powerful bomb blast, as opposed to car crashes on a highway, blows to the head on a football field or a bullet wound. These are the first wars in which soldiers, protected by strong armor and rapid medical care, routinely survive explosions at close range and then return to combat.
The bomb blasts, which throw off energy waves — atmospheric overpressures and underpressures — that are absorbed by the body, add a little-studied dimension to the trauma. Scientists are only now beginning to study the extent of the damage.
That soldiers are sometimes exposed to multiple blasts during a deployment, or can suffer from a vast combination of wounds, including shrapnel, burns, blows to the head, blast waves, lost limbs or internal injuries, can exacerbate brain trauma in ways unseen among civilians. “It is the black box of injuries,” said Dr. Alisa D. Gean, the chief of neuroradiology at San Francisco General Hospital and a traumatic brain injury expert who spent time treating soldiers at Landstuhl Regional Medical Center in Germany. “We’re at the tip of the iceberg of understanding it. It is one of the most complicated injuries to one of the most complicated parts of the body.”
These mild concussions, which do not necessarily lead to loss of consciousness, are easy to dismiss, simple to misdiagnose and difficult to detect. The injured soldiers can walk and talk. Their heads usually show no obvious signs of trauma. CT scans cannot see the injuries. And the symptoms often mirror those found in post-traumatic stress disorder, making it hard to distinguish between them. In fact, the two ailments often go hand in hand.
But the consequences of these seemingly small concussions can be far-reaching, leading to financial problems, job losses, divorce and mental health issues. The ramifications often go unseen by the military because symptoms often worsen once veterans leave the structure of the Army or Marine Corps for the unpredictability of civilian life.
Take the case of Mr. Owsley, a father of three, whose brain injury so impaired his reaction time and memory that doctors advised him not to work.
“I almost lost everything,” said Mr. Owsley, whose wife brought home the family paycheck for two years, working at a nursing home. “We were at the point of getting ready to lose the house and the cars. Then you start planning out things. I was planning to do suicide and make it look like an accident so my family would get the insurance.”
At first, he said, doctors missed his traumatic brain injury. “She told me nothing was wrong with me, but she gave me like 18 different medications, for pain, to go to sleep, for lots of other things,” he said of his first visit to a Veterans Affairs doctor at a facility in Fort Wayne, Ind.