Beyond The Battlefield: New Hope, But A Long And Painful Road, For Veterans Pulled From Death's Grasp
"Beyond The Battlefield" is a 10-part series exploring the challenges that severely wounded veterans of Iraq and Afghanistan face after they return home, as well as what those struggles mean for those close to them. Learn how you can help here. Other stories in the series can be found here. Listen to reporter David Wood discuss "Beyond The Battlefield" with NPR's Terry Gross here.
It was just another hot, dusty August day in Kabul five years ago, and Army Staff Sgt. Todd M. Nelson was traveling in just another convoy passing just another of the thousands of white Toyota Corollas that crowd Afghanistan’s capital. Except this Corolla was packed with explosives, and as Nelson's convoy passed, the suicide driver detonated them.
The blast blew the Corolla to bits and shredded the right side of the Toyota Land Cruiser where Nelson was sitting. The shock wave crushed his face, smashing the bones behind his cheeks, his forehead and his chin and nose. Jagged chunks of metal and glass slashed across his face, ripping off flesh and muscle and tearing away bone fragments. A fireball followed, searing his right arm, setting his head aflame beneath his helmet, burning off his nose and ears and eyelids, then charring what was left of his face.
A decade ago, Nelson would have had a slim chance of living after a blast like that. Recent major improvements in battlefield trauma care, swift medical evacuation and advances in burn surgery and reconstruction saved his life.
But it was close: When he arrived at the burn center at Brooke Army Medical Center (BAMC) in San Antonio, he was in a coma and the only evidence that he was still alive was his beating heart.
"These are particularly disturbing injuries," says Dr. Robert G. Hale, who performed many of the dozens of surgeries on Nelson's face in San Antonio. After the charred flesh is washed away with gentle streams of warm water, the wound has to be covered with skin grafts to prevent life-threatening infection, which can set in quickly. "If you don't close the wound within a month or two, many of these patients don't make it," Hale says.
Once the burn is covered, there's no way to operate to try to reconstruct the face without taking the skin back off -- or by burrowing through nearby flesh.
Meanwhile, as the skin graft heals, it contracts into painfully thick scars, pulling soft tissue such as eye openings, nostrils and mouths into grotesquely distorted shapes as it shrinks unevenly across the face. Each subsequent surgery forms more scars, with more painful shrinking and more contortions. Nelson's contracting scars flattened his nose, turned his one eyelid inside out and pulled down the corners of his mouth.
Trying to correct these distortions and enable severely burned patients to make normal facial expressions requires months and years of painful and debilitating surgeries, with outcomes often less than ideal. At some point most patients simply decide, as Nelson did, that enough is enough and wave off more surgery.
But that was years away. First, doctors cleaned and covered his wounds, and performed dozens of innovative surgeries to restore Nelson’s face to a form acceptable to him. In one series of operations, Hale pieced together the bone fragments of his jaw by operating through incisions inside Nelson’s mouth and neck.
From the very edge of death, Nelson was given new life -- and he seized the opportunity.
WARNING: Graphic images of medical procedures appear in the slideshow below.
Less than four months after he arrived in San Antonio in a coma, Todd Nelson walked onto the dance floor at the BAMC holiday ball with his wife, Sarah. His face at that point was still grotesquely disfigured. But he wore an American flag bandana tied proudly over his burned skull and his best dress uniform as he and Sarah swirled and turned among the dancers.
Over four years, Hale and other surgeons performed 43 surgeries on Nelson, leaving his face a patchwork of scar tissue and grafts of his own skin as well as synthetic skin, pig skin and cadaver skin. He has a prosthetic eye and a prosthetic ear that attaches with magnets to a metal plate in his head. ("I've almost lost it a couple of times," he says with a sheepish grin. "I got a backup ear, but it's one of those things you gotta worry about.")
Nelson can see and hear and speak normally, and he's gotten used to going out in public. That's a long way from his first glimpse of himself in the mirror after he was wounded. "I looked like Skeletor," he recalls. "All I could think to myself was, ‘I guess I can live with this.’ Because I felt fortunate just to be alive."
Yet Nelson's case also marks a limit as to what modern medicine can presently achieve. "There is no way to return these patients to function and aesthetics," Hale says. "We have run out of options with conventional treatment."
Even face transplants have proven less than satisfactory. Since 2005, when French surgeons performed the world's first facial transplant, the Defense Department has funded all five full facial transplant operations for American patients. The procedure sentences the patient to a lifetime of immuno-suppression treatment. "Once they stop that medicine, whatever body part you gave them from somebody else will be rejected," Hale points out.
Frustration with this apparent dead-end has led Hale and many others into a fast-paced research effort to perfect new techniques in regrowing the patient's own tissue. Hale is director of craniomaxillofacial (head, jaw, face) research at the U.S. Army Institute of Surgical Research in San Antonio and a consultant at the Armed Forces Institute of Regenerative Medicine.
He and other military researchers are working with scientists at the Department of Veterans Affairs, the National Institutes of Health and the Uniformed Services University of the Health Sciences in Bethesda, Md., and universities across the country to regenerate tissue lost in combat -- skin, muscle, bone, blood vessels, even nerves.
Some of their work, including human-engineered skin and spray-on skin made from a patient's own stem cells, will be put through clinical trials shortly aimed at winning a stamp of approval from the Food and Drug Administration. That may only be the beginning.
"Twenty years from now, I think we will be able to regenerate the entire face," Hale says.
THEIR SKIN WAS GONE
Hale, 54, was a highly successful surgeon with a booming practice in Los Angeles when he was summoned in 2003, as an Army reservist, to active duty as a trauma surgeon. Working in a field hospital in Kuwait, he experienced the first waves of the severely wounded as the Iraq war ignited into a raging and bloody insurgency. There were few surgeons on hand, and even fewer with his special skills in facial and jaw reconstruction.
"I saw soldiers with horrific injuries that conventional treatment could not even hardly close, much less make functional," he says.
Recognizing both a need and a calling, he instructed his wife to sell his lucrative private practice back home. Hale stayed on active duty, serving another tour in Afghanistan where there was such a shortage of medical staff that he treated his own infected tooth by pulling it himself, using forceps and a mirror.
Returning home to work with burned soldiers and Marines, Hale kept running across an ugly problem: Many of them were burned so badly that their skin was gone -- and with it the underlying layers of fat, muscle and other tissue that is essential in bringing blood to a skin graft sewn on top. Without blood and nourishment from underlying fat, grafted skin will die.
To get around the problem, Hale eventually performed several surgeries on Nelson and other patients in which he partially cut a piece of skin from one shoulder, sewing an end of it onto a wound and leaving the other end still attached to the shoulder so it could continue to carry blood and other nutrients into the skin.
The surgery would leave Nelson wearing a sheet of skin, or what surgeons call a "flap," with one end still attached to his chest and the other grafted onto his cheek. It would take 20 days for the flap to heal, drawing blood and nutrients from its new site on his face, before surgeons could safely sever the end from Nelson's shoulder.
These surgeries began months into Nelson's treatment. In the meantime he had become an outpatient at BAMC, had bought a nearby house and moved in with his family. While the flaps were healing, with the sheets of skin stretching between his shoulder and cheekbones, regular life went on, for weeks.
"You have to walk around San Antonio -- home improvement, grocery store -- everybody knows you, you look like Jabba the Hutt," Nelson says, a glint of humor in his eye. Asked how difficult that was for him, he shrugs. "You don't do as much socializing in the checkout line."
Nelson’s flap procedures didn't work perfectly. The blood supply tended to run out at the edges of the flap and the skin there would die. The operation produced more scarring and contractions that pulled his mouth out of shape.
"When it comes to skin grafts, it's roll of the dice as to how much of it is going to work and if it's gonna work at all," Nelson says. Above all, the skin didn't look right. The skin on his cheeks, from a graft that eventually did heal, is shoulder skin -- not facial skin.
"There is nothing on the body that looks like a face, except a face,” Hale says.