When it was time for Dustin Hill to receive his Purple Heart, he was wheeled from an aisle in the packed auditorium up a ramp and onto the stage. He wore glasses, warm-up pants, unscuffed running shoes, and a U.S. Army cap, under which was a white gauze bandage. His face was red with scars from the fire that had destroyed his Humvee in Iraq four months before. The smooth, red, round ends of his arms poked out of the sleeves of his jacket. There was a pink hollow where his right eye used to be.
“Specialist Hill is from Wyanet, Illinois,” said General C. William Fox Jr., the emcee. “In September, Specialist Hill sustained extensive burn and shrapnel injuries in the Green Zone in Baghdad when, on patrol, a vehicle-born improvised explosive device was detonated next to his Humvee. Specialist Hill is single and is accompanied here today by his mother, father, and two brothers.”
There is more to Hill’s story. He joined the National Guard in 2002 and was deployed in 2004. He was the only member of his squad in the Humvee; the rest were investigating an abandoned vehicle. A suicide bomber had pulled his car behind a passing convoy and, when he’d reached Hill’s stopped vehicle, blown himself up. Hill, on fire, was thrown free. He suffered third-degree burns over one third of his body. His entire right hand and the fingers on his left were burned so badly they would be amputated. He also had a broken femur, kneecap, and ankle. He is 22.
The applause for Hill lasted a full twelve seconds. He was the fifth of five wounded soldiers, or warriors, as they were called, to receive the Purple Heart at this ceremony, held at Brooke Army Medical Center at Fort Sam Houston, just outside downtown San Antonio. It was January 14, and most in the audience wore camouflage. The ceremony was a charged prelude to the official occasion that morning, the opening of the Army’s second amputee care center. The first had been opened at Walter Reed Army Medical Center, near Washington, D.C., in 2004. But with the violence in Iraq increasing, demand was high. This new facility at BAMC is 29,000 square feet, with state-of-the-art prosthetics and occupational and physical therapy rooms. To showcase what doctors at BAMC had already been doing with amputees, nine soldiers, each of whom had lost a limb, walked or were wheeled to the stage. Some, like B. J. Jackson, who stood on steel legs hidden under khaki slacks, had reentered civilian life. All nine held a long yellow ribbon, which Army Vice Chief of Staff General Richard A. Cody and Sergeant Major of the Army Kenneth O. Preston cut with a pair of oversized scissors.
At the reception afterward, men with hooks for hands mingled with men who still had all ten fingers. A four-piece military band played World War II—era Glenn Miller songs, and people milled about chatting. I watched Jackson walk among the guests, and I had to look closely to see any unsteadiness in his step. No one stared at Hill, who at one point was surrounded by his mother, Liz Kelm; General Fox, the commander of Fort Sam Houston; and General Cody. No one gawked at Joshua Forbess, who was one of only five survivors of a Blackhawk collision in 2003 and who has one ear, part of a nose, and an extensive scar running around the crown of his shaved skull. His head was shiny, especially the skin under his right eye, which had just been operated on. Forbess is stout and unself-conscious and looks like a large owl. He moved easily among the crowd, talking to friends and hospital staff. At one point an older woman walked up to him. “I need to give you a hug and a kiss,” she said, and did. A sergeant approached him and shook his hand. “You are a great warrior,” he said.
In much of the country, it’s easy to overlook the fact that we’re at war. You can’t possibly do that at Fort Sam Houston. There is a sense here of urgency and duty, and everywhere you turn you see camouflage and crisp salutes. If you have doubts about the war or its legitimacy, the doctors and nurses at BAMC don’t want to hear them, and neither do the soldiers, especially the ones who gave their arms and legs on the battlefield. They are still fighting. “You have to be a warrior once you come back,” says Corporal J.R. Martinez, who left most of the skin of his face in Iraq. “The battle in Iraq may have lasted a few minutes or a few hours, but the real battle starts when you come back.”
ALL WARS ARE DIFFERENT from the ones that came before. The main difference in the Iraq war is that an astounding 91 percent of the wounded have survived their injuries. By contrast, in World War II the figure was 70 percent, and in both Vietnam and the Persian Gulf wars, 76 percent. There are several reasons for this. Field doctors have better equipment now, plus they are truly mobile; surgeons can do trauma surgery out of backpacks and then, if necessary, airlift the wounded to BAMC or Walter Reed in 36 hours. The main reason, though, is the ceramic and Kevlar in their vests. U.S. soldiers wear 25 pounds of virtually impenetrable body armor, and much stronger helmets, so they’re not getting wounded as much in the vital organs.
But their limbs and faces are paying for it. Two thirds of the wounds in this war come to the arms, legs, and head. And if the wounds aren’t as deadly, they’re a lot more horrible. Multiple limbs lost. Burns over 80 percent of the body. As one doctor told me, “A lot of these guys should be dead.” The main causes of the wounds are explosions from mortars, grenades, and what the Army calls IEDs, improvised explosive devices. Other wars had bombs too, but the Iraqi insurgents are delivering them in frightening ways, via suicide drivers or remote control, bringing bombs up close to our soldiers, next to their Humvees (which are not, as many soldiers have complained, fully armored), even inside their tents.
The wounds are often complex ones—burns mixed with lost limbs, bone destroyed along with muscles and nerves, one leg shattered while the other is blown off. Dustin Hill’s injuries are about as complex as they come. Six days after he received his Purple Heart, Hill sat on a black couch in the amputee center’s occupational therapy room and tried to get some of his former life back. His therapist, Amy Hilliard, fitted him with a silicone myoelectric prosthetic hand that operates by responding to electrodes placed over upper arm muscles. When the patient flexes the muscles, they emit electrical impulses that open and close the hand. Hill’s right arm was bright red, like raw hamburger meat, while his left arm had a thick white gauze bandage on it. It took awhile to get the hand on Hill’s forearm, which had swelled up in the previous couple of days. At one point he grimaced. “Are you okay, Dusty?” asked his mother, who sat at his right and who accompanies her son almost everywhere he goes. He nodded. He is tall, thin, and soft-spoken. He joined the National Guard, he told me later, because he liked the uniform.
Hill was engaged in occupational therapy, which deals with the prosthetic hands. Just across the hall is a modern apartment with a bedroom and a kitchen, a kind of hands-on OT room, where patients learn all over again how to turn on a stove and open a jar of pickles. The new center also has a physical therapy lab, where patients work on basic motor skills, like walking. Patients who’ve lost legs are often outfitted with C-Legs, $45,000 computerized prosthetics that can be customized to the user’s gait. Two thirds of the amputees here have lost their legs, and they can be walking within weeks on new ones, which can then be covered by trousers.
Hands are not so easy. Once the prosthetic hand was on, Hill opened and closed the silicone fingers and thumb, looking quizzically at this robotic thing attached to his flesh. It was maybe the sixth time he had used it, and he still wasn’t comfortable with it. Hilliard began the morning’s therapy by holding out a stick of red licorice. Hill slowly reached for it. He closed the thumb and forefinger around the thin red candy, leaned forward, brought it all the way to his mouth, took a bite, leaned back, pushed his arm away again, and chewed. “Let me just say,” said Hilliard, “I’m impressed you did that reclined on the couch like you are. You really had to stretch for it.” Hill spent the next fifteen minutes methodically learning to feed himself again. It began to wear on him. “The hardest part about the exercise,” explained Sergeant Heather Martin, another occupational therapist, “is using your arm muscles to control the electrodes.” It’s tedious and it’s painful.
When the piece of candy became bite-size, Hill used his left arm to push his right arm the last couple of inches toward his mouth. “You see how close he got that to his mouth?” asked Kelm. “Yes,” replied Hilliard. “I’m very excited. You did awesome, Dusty. Awesome, ” Hill smiled. He was proud of himself, even this small thing, and his boyish grin cut through the red scars on his face.
BAMC IS THE ARMY’S most modern hospital, a huge seven-story, 450-bed facility built in 1996. From the expansive parking lot you can see, off to the west just above the horizon, the original BAMC, which was built in the late thirties and was on the forefront of treating wounded soldiers in World War II. But BAMC became best known during the Cold War. In 1949, worried about the possibility of massive burns from a nuclear attack, the U.S. government established BAMC’s burn unit, one of the first clinics devoted solely to traumatic burns. The Army doctors in the unit eventually helped develop many of the basic treatments for burns still used today, and BAMC became famed as a destination for both civilian and military victims. Though the fundamentals of burn treatment haven’t changed much in the past forty years—clean the wound, close it with a graft, and rehabilitate the skin—burn doctors and therapists have gotten a lot better at keeping patients alive. “Now,” says Captain Ted Chap- man, chief of occupational therapy at the burn center (as it’s now called), “patients with third-degree burns over eighty percent of their body are surviving. We have better medical care, so there’s less infection, the physicians are more advanced, and the speed from the battlefield to here is really high. Patients can be here from Iraq in a couple of days.”
One of the first soldiers to arrive at BAMC with serious burns from Iraq was J.R. Martinez. In April 2003 he was driving the rear Humvee in a 94-vehicle convoy through Karbala when the left front tire hit a land mine. Everyone else was thrown clear of the burning vehicle; Martinez was trapped inside. When his comrades finally got him out twenty minutes later, more than 40 percent of his body was burned, including almost all of his head. He was nineteen. When I met Martinez, he wore a knit cap because the right side of his skull was puffed out like a water balloon. He had just had his thirtieth surgery, and doctors had inserted two 500-cc bags of silicone under the part of his scalp where his hair still grew. For the next three months they would inject the bags with saline, expanding them and the healthy skin; three months down the road, there would be a flap of new skin, which they would remove and graft onto a part of his scalp where hair doesn’t grow. The procedure is one of the less painful ones Martinez has had to put up with.
It’s not enough that burns are horribly disfiguring; they’re also among the most gruesome of all indignities a body can suffer. From the beginning—when burns have to be thoroughly cleaned (infection is the biggest killer of burn victims) to closing the wounds with skin grafts and, finally, to the physical and occupational therapy, which involve constant stretching of skin that has no elasticity and wants to do nothing but tighten up—burns are pain. “Pain is our biggest obstacle,” says Chapman. “Getting the patient to tolerate the pain is the hard part.” And burns take a long time to heal. “After one surgery,” said Martinez, “you have to give that part of the body so much time to recover before you go back and cut on it again.” He showed me the work that had already been done. “All this skin,” he said, pointing to the left side of his face, “they brought up from my chest. They took out all the bad scarring on my face. Also, I had a big scar on the right side of my face, and they released it and made one thinner scar out of it. I’ve had seven operations on my eyes, which I couldn’t fully close before. They worked a little on my nose, my head, my hands.” He said he’s had a chance to get operated on at Vanderbilt University. He’s refused. “I said, ‘This is the place I want to be. This is the place that will get me back looking better than what I looked like before.’” Part of that is testimony to the reputation of BAMC’s burn center. But Martinez is like most soldiers here—they take great comfort in being treated by soldiers and with soldiers, especially ones with similar wounds. When they look around and see others with damaged faces and bodies, they don’t feel so isolated. They’re reminded that they’re still part of something bigger than themselves.
EVERY SOLDIER FIGHTS HIS BATTLE his own way. Joshua Forbess does it with dark humor. At the end of our first interview, he told me he would be easy to find again. “I’m always running around the hospital here,” he said. “Just look for the guy with no ear and half a nose.” When I did locate him a couple of days later and asked how he was doing, he snorted, “Living in paradise.”
Forbess is a survivor of one of the Army’s first big Iraq disasters: the midair collision of two Blackhawk helicopters over Mosul in November 2003. Forbess and four others lived, while seventeen died. He was burned over 11 percent of his body, mostly his head and arms, losing his right ear and a good deal of his nose. His lungs were so polluted from inhaling smoke that he could barely breathe, and his right wrist and left hand were broken. Worse, at least to Forbess: Five of the dead were men in his command. The guilt was crushing. “Some of us survivors feel we let our soldiers down, our comrades down, our superiors down,” he said. I asked him how he could feel that way after giving so much.
He laughed. “Ever been in combat?” he asked. No, I answered. “Well, not only did I lose my soldiers, I found myself asking, ‘Why did I survive the accident? Did I crawl out and leave them?’ I promised their families that I would bring them back alive, and I didn’t, so I feel at fault. Why should I feel at fault when there was nothing I could do? I still felt at fault for a long time. Unless you’re in the military, it’s hard to explain.” Forbess, who says he has loved the Army since he joined, in 1995, was visited at his hospital bed by an ill-equipped psychologist: “He had never been in combat, and he was telling me how I should feel. So I had to learn to deal with it on my own.”
For many soldiers at BAMC, handling their physical injuries can be a lot easier than dealing with their psychological wounds. In addition to the psychic turmoil of burns and amputations, these soldiers carry survivor’s guilt and suffer everything from nightmares and flashbacks to full-blown depression. “Over there, they’re scared all the time,” says BAMC social worker Michelle Cano, who has worked with both burn patients and amputees. “When they get back home alive, they ask, ‘Why me?’ They’re angry, mostly because it hurts. They’re angry at themselves, at the Army, and at God.” Both the amputee center and the burn center have social workers and psychologists who are addressing these issues. Cano says that in most cases, medication and counseling are helping.
In some ways, amputees have it easier than burn patients. Those who have lost a limb have lost a piece of themselves that can be given back, at least in a workable fashion. Burn patients, especially those with facial burns, lose a big part of their identity, the persona they present to the world. And it takes time to reconcile with the new, disfigured persona. Recovery is a highly individualized process, says Colonel H. D. Peterson, the former chief of the burn center’s clinical division. “It has nothing to do with the degree or size of the burn or injury,” he says, “and everything to do with what the person was like before the accident.”
When Martinez first saw his new face, he almost couldn’t bear it. He was so angry and depressed that he thought of killing himself. He sat for weeks alone in his room watching daytime TV talk shows and refusing to speak to anyone. But everything changed after he took a convalescent leave to his home in Dalton, Georgia, and was given a parade; then he went by his old high school and gave an impromptu talk to students. He was nervous at the beginning but confident at the end. “I amazed myself,” he said. “One point led to another, and by the end, those kids in that class were touched and motivated. I showed them that you can live your life no matter what troubles you’re faced with.” When he returned to BAMC, he began to visit the terrified, damaged newcomers: “I would tell them, ‘Hey, life goes on. I’m not a doctor saying you’re going to be fine. I’m showing you.’ When they’d ask, ‘Why me?’ I’d say, ‘But it’s not just you.’ And then I thought that maybe this is the reason this whole thing happened. I can use my experience to help other soldiers.”
One of the men he visited was Forbess. “J.R. came to my room right after I got out of ICU,” remembers Forbess. “We have a lot of similar injuries. He said, ‘Look at me. I still go out in public. I am who I am.’ That day he motivated me to look in the mirror for the first time.” And after weeks of dread, Forbess says, it wasn’t so bad. In fact, he was kind of relieved. And Forbess started to do what his comrade had done for him, going to visit the newly arrived. “I’d say, ‘Hey, look at me. I still go out. I am who I am.’ I vowed I’d never let another soul go through what I had to go through. As long as there’s one person there to listen, it means a world of difference.”
They’ve both visited Hill, who doesn’t have their commando-like bravado but who does have family support. “My entire family will be behind me,” says Hill. “If I need help, they’ll be there for me. It’ll be okay.” Chapman is optimistic about his patient: “He’s already ahead of schedule. His tolerance of pain is high, and he works hard.”
Like most soldiers, the burn patients and amputees are fatalistic about almost everything. If the bullet has your name on it, the old Army saying goes, there’s nothing you can do about it. And if you survive the hell of war, there must be a reason. “As I look back,” says Forbess, “it almost seems like fate. It’s fate I joined the military, it’s fate I joined the artillery, it’s fate I was in the helicopter wreck—so I could talk to other soldiers, help them out.”
Forbess just wants to return to his unit in his full capacity as an artilleryman. Martinez, the optimist, wants to eventually host his own talk show, a positive one, he says. Hill, the kid who joined the Guard because he liked the uniform, just wants to fish again. Each of them is proud of what he did, proud of his service, certain of its worth. They won’t admit to any regrets. And to a man, they wish they were back with their buddies. In this sense, the war in Iraq is no different from any other.