Shrapnel from mortar fire blew off nearly half of Erik Castillo’s skull, shattering the right side of his face and leaving him deaf in his right ear and limp on the left side. But today, he is walking with a cane and describing horrific injuries he doesn’t remember.
In previous wars, the 22-year-old would have been dead.
But soldiers such as Castillo who have traumatic brain injuries, amputations or other serious wounds are surviving thanks to protective gear and rapid medical care from the battlefield to the hospital.
The result is a 98 percent survival rate for troops wounded in Iraq and Afghanistan.
"They’re getting medical care within minutes of being injured," said Dr. Michael Kilpatrick, deputy director for deployment health support in the Office of the Deputy Assistant Secretary of Defense. "We have really changed the way care is delivered in this war."
A new legion of survivors with severe and often longlasting injuries has emerged, and with them come new challenges. Government and medical authorities are facing rehabilitating and eventually integrating severely disabled veterans — especially those with traumatic brain injuries — back into their communities.
They are also looking into better body armor, which is saving lives but not limbs, leaving many soldiers amputees.
The U.S. is confronting the medical consequences of terrorist warfare.
After a year filled with surgeries, depression, rehabilitation and hope, Castillo is living out those consequences.
"I have a lot of friends from Vietnam, World War II and the Gulf War, and they say they look at me as a miracle," Castillo said. "I feel lucky, but . . . I guess I’ll feel luckier later on."
Castillo was checking his Humvee in Baghdad’s Green Zone, a safe area within one of Saddam Hussein’s former compounds, when an explosion knocked him unconscious.
Fourteen other soldiers were hurt, but none of them as severely as Castillo.
Nearly half his skull was shattered from two pieces of metal that hit below his right ear, in the small space his helmet didn’t cover.
"The exact place where the shrapnel went in my head was where the Kevlar (helmet) ended," he said. "It went into the perfect spot to hit me."
Improved body armor and helmets have saved soldiers’ lives by protecting their chests and abdomens.
But other areas of the body, especially arms and legs, remain vulnerable.
That’s why so many veterans are coming back from Afghanistan or Iraq as amputees, Kilpatrick said.
Many have multiple amputations or extremities with severe injuries.
As of June 30, 264 military personnel with amputations had been treated at Walter Reed Army Medical Center in Washington, D.C., and Brooke Army Medical Center at Fort Sam Houston, Texas.
Of that number, 42 had multiple amputations.
Many were victims of improvised explosive devices, suicide bombs or other terrorist warfare.
"With continual insurgency combat, the injuries are in the extremities, so the focus of my folks has been amputations," Kilpatrick said.
With extremity wounds in mind, researchers are looking at ways to redesign the body armor to better protect the arms, legs and sides.
Castillo, who had not yet put on his body armor when the explosion occurred, said the gear became increasingly important amid the danger and chaos in Iraq.
Soldiers traveling as he did, carrying politicians and U.S. contractors, were required to wear the body armor once vehicles were moving.
Protective plates were later added to the vests.
And Castillo recalls trying unsuccessfully to keep protective material attached to his sides, which were not covered by the body armor.
"When we got there, a lot of people got injured from (the body armor) not protecting us," Castillo said in an interview at his rehabilitation center in Phoenix. "You think about it once or twice, but . . . you never think that’s going to happen to you. You don’t think about getting shot or getting in an explosion."
The difference this time is that military personnel are living to talk about their blast injuries, Kilpatrick said.
Medical personnel with backpacks containing lifesaving equipment travel behind soldiers.
Tents for medical procedures can be erected in minutes.
And planes with medical teams and equipment comparable to a hospital intensive care unit move the wounded to major hospitals within days.
"Wounds to the chest and abdomen were wounds that resulted in death to military personnel in the past," he said.
Along with rapid surgical care, "the body armor has created a category of patients we wouldn’t have had to deal with before."
In Ward 57 at Walter Reed Army Medical Center, amputees are visited by peers also living without a limb. Foreseeing the influx of amputees from the wars in Iraq and Afghanistan, the Amputee Coalition of America began the training program with "peer visitors" and is expecting great things from the newly amputated veterans, said Paddy Rossbach, president and chief executive officer of the coalition.
"They are eventually going to become our wonderful, wonderful role models for people in civilian life," she said. "They are an example of what can be achieved with the best prosthetic care."
But while medical authorities have a long history of treating amputees, their knowledge of traumatic brain injury is in its infancy.
Brain injuries appear to account for a larger portion of the wounded in Iraq and Afghanistan than in other recent wars, according to a May 19 report in the New England Journal of Medicine.
An estimated 22 percent of wounded soldiers passing through Landstuhl Regional Medical Center in Germany had brain injuries, compared with 12 percent to 14 percent during Vietnam.
Today, health care providers routinely screen veterans wounded from blasts or other events that put them at risk for brain trauma.
Of all the blast victims evaluated at Walter Reed Army Medical Center from January 2003 to February 2005, 59 percent were diagnosed with traumatic brain injuries, according to the journal.
During that time, the medical center treated more than 450 patients with traumatic brain injuries.
Doug Mitchell, chairman of the social work department at the Carl T. Hayden Veterans Affairs Medical Center in Phoenix, said doctors are starting to take a closer look at injured veterans and refer them for neuroevaluation, something they might not have done before.
"All we can do is reach out to them and find out if something is wrong," he said.
Veterans with severe blast injuries, especially traumatic brain injuries, will need a level of ongoing health care and in numbers that the nation hasn’t seen before, health care authorities said.
Castillo, who has had months of intensive residential rehabilitation, is an example, said Irwin Altman, executive director for Gentiva Rehab Without Walls where he is undergoing rehabilitation.
"This is an important case, not just for us, but for the government to see how best to get the wounded back into their communities," he said.
In the next several weeks, Castillo is hoping he can leave his rehabilitation center and live with his brother in Ahwatukee Foothills.
In Arizona, about eight people have sought help for either amputations or a traumatic brain injury, according to the VA Medical Center.
But medical officials suspect there are many more with brain injuries.
One symptom is an inability to know an injury has occurred.
Castillo said he doesn’t remember anything that happened the morning of the blast. His commander told him how he was wounded.
Today, pieces of his skull remind him how far he’s come, but his limp left side reminds him of how far he still has to go, he said.
"The way I was before, I wasn’t used to failing at anything," he said. "I have to make an effort, or I’m going to be like this for the rest of my life."